ROBERT 

BURR 
LIVINGSTON 


3  1822  00181  9697 


Bfn 


Dicious     Circles 

in 

Disease 


(a)   CARDIAC   FAILURE 

laryngitis 


(b)   PULMONARY  TUBERCULOSIS 

Plate  i.— Concurrent  Circles. 


Vicious  Circles 

in 

Disease 


BY 
JAMIESON   B.   HURRY,  M.A.,   M.D.  (Cantab.) 

Author  of  "  Poverty  and  its  Vicious  Circles," 
Etc.,  Etc. 


Mitb  ^lustrations 


THIRD  AND  ENLARGED  EDITION 


PHILADELPHIA  : 

P.    BLAKISTON'S   SON    &   Co., 

1012,  WALNUT  STREET. 

1919 


Iboc  Opu0 


preface  to  the  Jfiret  Ebition. 


HIS  MONOGRAPH  represents  the  first  at- 
tempt to  deal  systematically  with  Vicious 
Circles  in  Disease,  and  is  offered  to  the 
Profession  with  a  full  consciousness  of 
many  shortcomings. 

Such  an  exploration  into  a  new  field  of  pathological 
enquiry  needs  no  small  circumspection.  But  care 
has  been  taken  to  quote  freely  from  recognised 
authorities  so  that  the  reader  will  have  before  him 
the  evidence  for  the  propositions  advanced. 

The  array  of  Vicious  Circles  brought  together 
appears  so  overwhelming  in  its  cumulative  weight  as 
to  justify  the  conclusion  that  such  Circles  play  a 
role  of  great  importance  in  pathology.  If  this  view 
is  correct,  the  subject  is  one  which  no  practitioner  of 
the  ars  medendi  can  afford  to  neglect.  Its  study  will 
conduce  to  increased  accuracy  of  diagnosis,  prognosis 
and  treatment.  Especially  in  regard  to  treatment 
will  there  be  gain,  for  full  of  truth  is  the  old  maxim  : 
Qui  bene  diagnoscit  bene  medebitur. 

Most  of  the  Chapters  have  appeared  in  the  columns 
of  the  British  Medical  Journal,  The  Lancet,  The 
Practitioner  and  the  Medical  Press,  and  I  am  indebted 
to  the  courtesy  of  the  respective  Editors  for  per- 
mission to  reprint.  My  thanks  are  also  due  to  many 
friends  for  assistance  and  encouragement. 

My  friend  Dr.  Harry  Campbell  has  kindly  read 

through  the  proof-sheets. 

J.  B.  H. 

WESTFTELD,  READING. 
February   1st,    1911. 


Contents. 


Introduction  . .          . .          . .          .  .          . .  xvii 

CHAPTER   I. 
The  Aetiology  of  Vicious  Circles  . .          . .       i 

CHAPTER   II. 
The  Classification  of  Vicious  Circles      . .          . .       7 

CHAPTER  III. 

The  Nervous  System        . .          . .          . .          . .       9 

CHAPTER  IV. 

The  Cardio- Vascular  System       . .          . .          . .     35 

CHAPTER   V. 

The  Respiratory  System  . .          . .          . .     71 

CHAPTER  VI. 

The  Digestive  System       . .          . .          . .  87 

CHAPTER   VII. 
The  Urinary  System         . .          . .          . .          . .   121 

CHAPTER  VIII. 
The  Sexual  System          137 


Xll. 


Contents 


CHAPTER  IX. 

Constitutional  Disorders  •  •   J53 

CHAPTER   X. 
The  Eyes  and  Eye-lids   . .          . .  . .   171 

CHAPTER  XI. 
The  Nose . .   189 

CHAPTER   XII. 
The  Throat  201 

CHAPTER  XIII. 
The  Ear ..         . .  210 

CHAPTER  XIV. 
The  Skin 219 

CHAPTER  XV. 
Veterinary  Diseases          237 

CHAPTER   XVI. 
Plant  Diseases        . .          . .          . .          . .          . .   255 

CHAPTER  XVII. 
The  Vicious  Circle  as  a  Cause  of  Death         . .   265 

CHAPTER   XVIII. 
Artificial  Circles 277 


Contents  xiti. 

Page 
CHAPTER  XIX. 

The  Breaking  of  the  Circle  by  Nature  . .   291 

CHAPTER   XX. 

The  Breaking  of  the  Circle  by  Art        . .          . .   301 
I.     Hygienic  Measures 
II.     Drugs 

III.     Surgical  Appliances 
IV.     Surgical  Operations 

CHAPTER   XXI. 

Conclusion  . .          .  .          . .          . .          . .          . .   353 

Index  .  .          .  .          .  .          . .          . .          . .   355 


3Uu8trations 


Plate  Page 

I.     Concurrent  Circles        . .  Frontispiece 

II.     Circles   associated   with  the   Nervous 

System        . .          . .          . .          . .     n 

III.  Circles    associated    with    the    Cardio- 

Vascular  System    . .          . .          .  .     37 

IV.  Circles  associated  with  the  Respiratory 

System         .  .          . .          . .  73 

V.     Circles  associated  with  the  Digestive 

System        . .          . .          . .          . .     89 

VI.     Circles    associated   with   the   Urinary 

System        . .          . .          . .          . .   123 

VII.     Circles    associated    with    the    Sexual 

System         . .          . .          . .          . .   139 

VIII.     Circles  associated  with  Constitutional 

Diseases       . .          . .          . .          . .   155 

IX.  Circles  associated  with  the  Eyes  .  .  173 

X.  Circles  associated  with  the  Nose  .  .  191 

XI.  Circles  associated  with  the  Throat  .  .  203 

XII.  Circles  associated  with  the  Bars  . .  213 


xvi.  3Uii9tration6 

Plate  PaSe 

XIII.  Circles  associated  with  the  Skin     . .   221 

XIV.  Circles  associated  with  Veterinary 

Diseases       . .          . .  •  •   239 

XV.  Circles  associated  with  Plant  Diseases  257 

XVI.  The  Circle  as  a  Cause  of  Death         . .  267 

XVII.  Artificial  Circles  . .  . .  279 

XVIII.  The  Breaking  of  the  Circle  by  Nature  293 

XIX.     The  Breaking  of  the  Circle  by  Hygienic 

Measures     . .          . .          . .          . .   307 

XX.     The  Breaking  of  the  Circle  by  Drugs  315 

XXI.     The  Breaking  of  the  Circle  by  Surgical 

Appliances  . .          . .          . .          . .   335 

XXII.     The  Breaking  of  the  Circle  by  Surgical 

Operations  . .          . .          . .          . .   341 


Jntrobuctfon. 


VICIOUS  Circle  in  pathology  (circulus 
vitiosus,  cercle  vicieux,  Zirkelschluss, 
circolo  vizioso)  is  defined  in  Murray's 
New  English  Dictionary  as  "a  morbid 
process  consisting  in  the  reciprocal  con- 
tinuation and  aggravation  of  one  disorder  by 
another."  In  other  words  the  process  represents 
such  a  reaction  of  a  disorder  on  its  cause  that  such 
cause  is  perpetuated  or  intensified.  Cause  becomes 
effect  and  effect  cause. 

This  meaning  of  Vicious  Circle  is  transferred  from 
its  earlier  use  in  logic  where  the  expression  connotes 
a  fallacious  mode  of  reasoning  in  which  a  proposition 
is  used  to  establish  a  conclusion,  and  is  afterwards 
proved  by  means  of  the  conclusion  which  it  has 
been  used  to  establish. 

Although  the  expression  Vicious  Circle  has  been 
used  by  pathologists  for  over  a  century  and  enjoys 
the  advantage  of  brevity,  it  is  not  altogether  a 
fortunate  one,  conveying  as  it  may  do  the  idea  of 
form  rather  than  of  process  or  action.  From  this 
point  of  view  the  expression  "  circular  reaction  " 
introduced  by  Prof.  J.  M.  Baldwin  to  designate 
"  a  condition  which  keeps  itself  going  by  repro- 
ducing the  conditions  of  its  own  stimulation " 
is  preferable.  A  further  advantage  of  this  term  is 
that  it  may  be  applied  to  reciprocally  acting  physio- 
logical as  well  as  pathological  processes,  such  a 
prefix  as  beneficent  or  injurious,  healthy  or  morbid 
being  added  as  required.  On  account  of  its  hoary- 
antiquity  the  term  Vicious  Circle  has  been  retained 
in  the  title  of  this  Book  in  spite  of  the  objection 
referred  to.  In  the  letterpress  both  expressions  are 
used. 

xvii. 


xviii.       iDicious  Circles  In  2>isea0e 

Vicious  Circles  play  a  part  of  immense  importance 
in  the  mechanism  of  disease.  They  are  responsible 
for  the  perpetuation  and  aggravation  of  morbid 
processes,  for  the  destruction  of  organs,  for  the  end- 
ing of  life  itself.  A  large  proportion  of  all  deaths 
are  accelerated  by  the  intervention  of  this  compli- 
cation, a  result  which'  applies  as  much  to  the 
animai  as  to  the  vegetable  kingdom. 

This  subject  has  hitherto  received  but  little 
attention  from  either  the  zoo-pathologist  or  the 
phyto-pathologist.  No  "  system  of  medicine  "  dis- 
cusses the  pernicious  influence  of  the  Vicious  Circle 
on  the  progress  of  disease  ;  no  text-book  of  thera- 
peutics guides  the  practitioner  in  his  search  for  the 
locus  minoris  resistentice,  so  that  natura  medicatrix 
may  once  again  resume  her  beneficent  sway. 

In  the  normal  course  of  events,  the  reactions 
provoked  in  response  to  injury  are  of  a  kind  calcu- 
lated to  promote  recovery.  Such  disorders  may  be 
described  as  self-limiting  and  the  main  task  of  the 
physician  is  to  further  and  control  such  beneficent 
reactions  as  tend  to  readjustment. 

On  the  other  hand  when  disease  is  complicated  by 
injurious  reactions  the  art  of  therapeutics  is  con- 
fronted with  problems  of  greater  complexity. 
The  physician  has  no  longer  merely  to  deal  with  a 
morbid  process  which  Nature  is  doing  her  best  to 
rectify.  So  far  as  the  factors  that  go  to  make  up 
the  pernicious  sequence  are  concerned,  her  beneficent 
influence  becomes  maleficent.  The  vis  medicatrix 
becomes  the  vis  vastatrix  ;  the  gyration  must  be 
arrested  before  recovery  can  take  place. 

A  great  advantage  of  isolating  the  process  of 
the  Vicious  Circle  for  separate  study  is  that  such 
isolation  conduces  to  clearness  of  thought  and  to  an 
insight  into  the  complex  processes  involved.  More- 
over such  isolation  assists  in  the  philosophical 
grouping  of  a  mass  of  facts  which  otherwise  would 


3ntrobuction  xix. 


remain  membra  disjecta  and  allows  such  facts  to  be 
arranged  in  their  several  niches  of  pathological 
phenomena.  Specialisation  is  an  application  of  the 
common-sense  principle  "  one  thing  at  a  time," 
and  is  a  valuable  aid  to  research,  so  long  as  other 
aspects  of  a  problem  are  not  lost  sight  of.  The 
search  for  such  inter-dependences  supplies  a  good 
discipline  for  the  clinician  who  is  encouraged  to 
study  disease  both  in  its  immediate  and  remote 
effects.  The  subject  has  also  intimate  relations 
with  therapeutics.  The  deeper  the  insight  into  the 
problems  of  disease  the  clearer  the  vision  that 
adapts  remedy  to  disorder.  Attention  will  be 
directed  to  the  influence  of  reactions  on  their  cause, 
a  most  important  subject  that  hitherto  has  been 
singularly  neglected. 

This  Volume  is  mainly  devoted  to  Vicious  Circles 
in  human  pathology  ;  only  brief  reference  is  made 
to  the  same  process  as  complicating  diseases  of 
the  lower  animals  or  of  plants.  But  an  enquiry 
into  the.  latter  will  yield  some  important  results 
well  worthy  of  the  labour.  Fresh  light  will  be 
thrown  on  the  problems  of  pathology  and  of  rational 
therapeutics.  A  special  emphasis  is  laid  on  the 
necessity  of  "  breaking  the  Circle "  in  order  to 
secure  recovery,  and  instances  are  given  to  shew 
how  Circles  may  be  broken  both  by  Nature  and  by 
Art. 

The  conception  of  the  Vicious  Circle  is  very 
ancient.  Asclepiades  (ca.  124  B.C.)  probably  referred 
to  it  when  he  opposed  the  Hippocratic  "  Nature  is 
the  healer  of  disease  "  by  the  dictum  "  Not  only 
is  Nature  useless,  but  it  is  sometimes  harmful." 
Galen  (ca.  130  A.D.)  gives  the  following  illustration 
of  the  morbid  process  : 

To,  Kara  TU'eu/xofct  TGJI>  eA/cojf  Suo-taTorara'  \a)pl<;  p.€i> 
"yap  TOV  fttJTTew  OVK  a.v  CKKapOapOtCrj,  ft^Trovitov  o  cVi- 
?i'  aXX'yjXcDZ'  ovv  aurots  KV/cXeirat  TO  KOLKOV. 


IDictous  (Tirdee  in  Disease 


"Ulcers  of  the  lung  are  most  difficult  to  heal  ; 
for  they  cannot  be  cleansed  apart  from  coughing, 
and  by  coughing  they  are  torn  further.  Thus 
owing,  so  to  speak,  to  a  reciprocity  of  action,  the 
disorder  revolves  in  a  circle."1 

The  subject  as  a  whole  deals  with  conditions  in 
which  Nature's  attempt  to  cure  reflects  small  credit 
on  her  provisions,  and  the  study  will  be  found  full 
of  suggestion  and  guidance  for  the  philosophic 
physician.  Illustrations  are  so  helpful  in  visualiz- 
ing ideas  that  it  has  been  thought  well  to  introduce 
a  considerable  number.  Especially  may  they  be 
commended  to  teachers  : 

Segnius  irritant  animos  demissa  per  aurem 
Quam   quae  sunt   oculis   subjecta  fidelibus. 


Galen  Methodus  Medendi,  V.  //.,  (Kiihn's  ed.  X.,  p.  360). 
The  following  is  the  Latin  version  :  "  Ulcera  pul- 
monis  difficillime  sanantur,  ut  quae  nee  citra  tussim 
expurgare  possis,  et  si  tussim  excites,  lacer averts. 
Itaque  quasi  per  mutuas  operas  malum  iis  in 
orbem  redit."  Cf.  also  Neuburger,  History  of  Medi- 
cine, I.,  p.  204. 


Chapter  ©ne 


THE  AETIOLOGY  OF  VICIOUS  CIRCLES 

HE  Vicious  Circle  is  a  morbid  process  to 
which  all  organised  animals  and  plants 
are  liable.  This  phenomenon  is  associ- 
ated with  differentiation  of  structure 
and  function,  and  illustrates  a  great 
physiological  law  applicable  to  all  but  the  lowest 
living  things. 

Throughout  life  there  is  a  constant  process  of  re- 
ciprocation taking  place  between  the  various  organs 
and  functions  both  in  animals  and  in  plants.  In 
animals  the  nervous,  the  cardio-vascular,  the  respir- 
atory, the  digestive  and  other  systems  are  intimately 
associated  with  each  other,  their  functional  activ- 
ities being  harmonised  by  the  all-controlling  nervous 
system,  increased  or  diminished  requirements  in  one 
direction  being  balanced  by  the  necessary  adjust- 
ments in  another.  Moreover  a  circulating  fluid 
supplies  to  each  organ  the  kind  and  quantity  of 
nutriment  required,  while  the  waste  products  that 
would  clog  further  activity  are  removed. 

The  corresponding  correlations  as  seen  in  plants 
are  less  obvious  than  they  are  in  animals.  There  is 
neither  an  all-controlling  central  nervous  system,  nor 
a  circulating  nutrient  fluid  at  all  comparable  with 
the  blood.  Nevertheless  in  principle  the  phenomena 
of  correlation  are  the  same,  and  are  controlled  by 
stimuli  connecting  every  part  of  the  organism. 
This  applies  to  the  shoots,  leaves,  cortex,  cambium, 
roots,  in  fact  to  every  organised  structure  of  the 
plant,  although  the  inter-dependences  are  more 


lDiciou0  (tfrdes  in  Dieeaee 


obvious  in  some  cases  than  in  others.  In  brief,  both 
in  animals  and  plants  the  vital  mechanism  is  carried 
on  by  means  of  an  ever-acting  chain  of  complex 
interactions.1 

Even  within  the  limits  of  health  there  are  frequent 
disturbances  of  the  harmonious  co-operation  between 
various  organs.  These,  however,  induce  reactions 
which  restore  the  natural  state  of  equilibrium. 
Only  when  the  disturbance  is  so  severe  that  rapid 
restoration  is  impossible  does  the  condition  become 
pathological. 

In  disease  the  physiological  correlations  are  thrown 
into  confusion.  Disorder  in  one  organ  frequently 
awakens  disorder  in  other  associated  organs  which 
in  turn  react  injuriously  on  the  first,  so  that  a 
circular  sequence  of  pathological  reactions  is  estab- 
lished. Doubtless  to  some  extent  organs  can  give 
vicarious  assistance  to  one  another  in  difficulty  and 
when  the  disturbance  is  only  slight  this  relief  may  be 
sufficient  to  allow  of  recovery. 

But  such  assistance  is  of  limited  potency,  at  any 
rate  in  animals  whose  organs  are  worked  nearly  up 
to  their  maximum  capacity.  In  plants,  on  the 
other  hand,  there  is  greater  opportunity  for  vicarious 
activity,  since  there  is  less  specialisation  of  structure, 
and  there  is  always  the  possibility  of  developing 

1  With  the  progress  of  our  knowledge  of  cellular  physiology 
and  pathology  it  may  be  possible  to  pursue  the 
process  of  the  Vicious  Circle  into  the  mechanism 
of  the  individual  cell,  which  forms  the  basis  of 
all  vital  processes.  In  unicellular  organisms  all 
functions  are  carried  out  in  the  one  cell  ;  but 
special  adaptations  are  so  microscopic  as  to  be  in- 
distinguishable in  detail.  We  do  not  know  whether 
an  elaborate  differentiation  exists  in  the  cell, 
or  whether  the  cell  taken  as  a  whole  is  able  to  act 
like  the  complex  apparatus  of  a  higher  plant  or 
animal  which  may  consist  of  millions  of  cells. 


fresh  organs  such  as  roots,  shoots,  leaves,  flowers  etc. 

In  both  animals  and  plants,  moreover,  vicarious 
assistance  often  has  unfortunate  effects,  since  by  it  a 
second  organ  or  set  of  organs  is  in  turn  involved  in 
difficulties,  over-taxed  and  perhaps  deranged  by  the 
unusual  demands  made  upon  it.  In  the  words  of 
Mitchell  Bruce  "  vicarious  help  ends  in  a  Vicious 
Circle." 

In  the  case  of  the  animal  the  process  may  be 
illustrated  by  cardiac  disease  which  affects  the 
nervous,  the  respiratory,  the  digestive  and  other 
systems  sympathetically,  while  these  secondary 
disorders  in  their  turn  injure  the  organ  primarily 
affected.  Thus  is  the  circulus  vitiosus  established. 

In  the  diseased  plant  similar  injurious  inter- 
dependences are  observed.  A  common  illustration 
is  afforded  by  root  starvation,  leading  to  an  inade- 
quate supply  of  nutritive  material  to  the  assimilating 
leaves.  Their  metabolic  activity  is  impaired  and 
such  impairment  reacts  injuriously  on  all  other 
organs.  The  formation  of  vessels  in  the  xylem  is 
checked.  The  sieve  or  phloem  tissues  are  less  able 
to  transport  products  of  assimilation  to  the  roots. 
Further  root  starvation  takes  place  and  the  sequence 
of  events  is  repeated. 

A  similar  concatenation  of  injurious  factors  may 
start  from  any  other  organ.  If  the  leaves  of  a  plant 
are  so  feebly  illuminated  that  assimilation  is  reduced 
to  a  minimum,  the  results  are  far-reaching.  The 
stem  remains  thin  ;  the  growth  of  the  cambium 
layer  is  arrested  ;  the  supplies  of  nutriment  passing 
to  the  roots  are  insufficient  for  their  growth  and  for 
the  formation  of  new  root-hairs.  Absorption  of 
water  and  salts  is  interfered  with,  and  this  in  turn 
further  paralyses  the  formation  of  chlorophyll  and 
the  process  of  photo-assimilation.  Here  also  is 
established  a  mutual  causal  relation  between  disease 
of  various  organs. 


IDicious  Circles  in  disease 


There  is,  however,  a  striking  difference  in  the 
manifestation  of  the  morbid  process  in  animals  and 
in  plants. 

In  animals,  owing  to  the  higher  differentiation  of 
organs,  numerous  specific  circuli  vitiosi  are  met 
with,  and  additional  examples  are  constantly  being 
discovered.  Thus  disease  of  the  blood  provokes 
disease  in  other  tissues,  which  in  their  turn  pour 
products  of  perverted  activity  into  the  blood,  and 
it  is  possible  to  study  this  endless  chain  of  disorder 
link  by  link. 

Future  research  may  yield  similar  results  in  plant 
pathology.  But  at  present  specific  effects  of  morbid 
reactions  are  but  little  understood.  On  the  other 
hand  the  general  principle  is  in  universal  operation, 
manifesting  itself  not  by  specific  results  but  by  the 
production  of  lowered  resistance  to  morbific  agencies, 
and  playing  a  part  of  great  importance  in  the 
growth  and  life-history  of  the  plant.  For  example, 
lowered  resistance  permits  parasitic  invasion  and 
this  in  turn  further  weakens  resistance.  The  lower 
the  resistance  the  more  rapid  is  the  progress  of  the 
parasite,  while,  on  the  other  hand,  the  rapid  progress 
further  lessens  resisting  power. 

The  several  organs  and  functions  in  animals  and 
plants  vary  in  the  power  of  resisting  morbific  influ- 
ences. This  varying  liability  depends  on  numerous 
factors,  such  as  heredity,  age,  environment,  nutrition 
and  so  forth.  Hence  it  is  that  injurious  circular 
reactions  are  more  often  observed  in  some  organs 
than  in  others,  at  some  periods  of  life  than  at  others. 
Certain  Vicious  Circles  are  prevalent  in  youth,  others 
in  advanced  life.  Some  organs  succumb  readily  to 
malnutrition,  others  to  fungus  or  bacterial  invasion. 
There  is  indeed  an  infinite  variety  in  the  influence 
exerted  by  pathogenic  factors  and  in  the  response 
made  by  the  living  organism  and  its  tissues. 

Other  Vicious  Circles  result  from  the  reciprocal 


aetiology 


reaction  on  each  other  of  a  disorder  and  its  symptoms. 
Of  such  a  process  numerous  illustrations  will  be 
described  in  the  following  pages.  They  are  especially 
common  in  neurasthenia.  For  example,  some  neuro- 
paths suffer  from  insomnia  which  in  its  turn  perpetu- 
ates the  neurosis.  Others  may  be  tormented  by 
auto-suggested  cardiac  disorder  which  further  depre- 
ciates their  reserve  stock  of  energy,  and  so  forth, 
lyewandowsky  thus  refers  to  this  group  of  circular 
reactions  : 

"  A  highly  injurious  Vicious  Circle  is  formed  as 
a  result  of  the  increased  irritability  due  to  exagger- 
ated functional  activity  in  neurasthenia.1 

The  two  great  causes  of  the  morbid  process  dis- 
cussed in  this  Volume  may  then  be  summed  up  as 
disturbed  correlations  between  organs  or  parts  of 
organs,  and  secondly  the  injurious  reaction  of 
symptoms  on  the  primary  disorder.  These  processes 
constitute  a  large  part  of  the  mechanism  of  disease. 

There  is  probably  no  disease  either  in  animals  or 
plants  in  which  all  the  reactions  provoked  by  the 
morbific  factors  are  either  beneficent  or  maleficent. 
Both  tendencies  are  simultaneously  in  operation  and 
the  result  of  the  disease  depends  on  the  relative 
potency  of  those  beneficent  and  maleficent  reactions. 
Happily  in  the  great  majority  of  cases  the  beneficent 
reactions  prevail  and  the  injurious  ones  are  insigni- 
ficant in  their  action  or  wholly  obscured  in  their 
manifestation.  Where,  however,  the  maleficent  re- 
actions are  dominant  the  Vicious  Circle  comes  into 
operation,  leading  to  a  perpetuation  or  aggravation 
of  the  morbid  process  or  possibly  death.  Under 
yet  other  circumstances  there  may  be  something 
like  "  an  equation  of  counteracting  processes  "  so 
that  the  diseased  organism  remains  in  an  approxi- 
mately stationary  condition,  the  forces  tending  to 

1Handbuch  der  Neurologic,  V.  (iv.),.p.  610. 


Dicious  Circles  in  Dieease 


recovery  being  neutralised  by  opposite  forces.  Time 
must  be  given  to  allow  of  reparative  processes  to 
exert  their  influence  and  perchance  gain  the  upper 
hand.  As  Clifford  Allbutt  puts  it  :  "  Such  a  Vicious 
Circle  may  be  established  that  ....  if  recovery 
is  to  take  place,  the  tension  between  the  opposing 
forces  must  be  released — the  deadlock  must  be 
overcome — even  if  some  considerable  oscillation  in 
the  direction  of  danger  have  to  be  reckoned  with."1 
Such  then  appears  to  be  the  pathological  basis 
of  the  circuit  vitiosi  met  with  in  animal  and  plant 
diseases.  This  Volume,  however,  is  mainly  con- 
cerned with  this  morbid  process  as  met  with  in 
human  pathology,  and  we  may  now  pass  on  to 
discuss  this  narrower  operation  of  a  general  principle. 


1  Clinical  Journal,  III.,  p.  194. 


Chapter 


THE    CLASSIFICATION    OF    VICIOUS 
CIRCLES 

|N  the  Chapter  dealing  with  ^Etiology 
the  origin  of  Vicious  Circles  was  attri- 
buted to  a  disturbance  of  the  physio- 
logical interdependence  of  organs  and 
tissues.  That  disturbance  may  shew 
itself  in  a  great  variety  of  disorders.  These  will 
be  considered  in  connection  with  the  various  systems 
of  the  body,  thus  following  the  usual  classification 
adopted  in  works  on  medicine.  This  arrangement 
is,  however,  based  rather  on  convenience  than  on 
principle,  since  many  injurious  circular  reactions 
are  not  confined  to  a  single  system,  but  reverberate 
far  and  wide  ;  in  such  cases  there  may  be  a  doubt 
under  which  system  they  may  most  appropriately 
be  grouped. 

Another  classification  is  one  based  on  the  number 
of  the  circular  reactions  provoked  by  a  given  dis- 
order. The  injurious  sequence  may  be  limited  to  a 
single  reaction  on  which  treatment  can  therefore  be 
concentrated.  On  the  other  hand  there  may  be 
multiple  concurrent  reactions,  the  effects  of  which 
on  the  primary  disorder  are  cumulative  and  conse- 
quently far  more  difficult  to  arrest.  Examples  of 
such  concurrent  Vicious  Circles  are  shewn  in  plate 
I.  a,  b,  where  cardiac  failure  and  pulmonary  tuber- 
culosis are  shewn  to  be  thus  complicated.  It 
would  have  been  easy  to  indicate  an  even  larger 
number  of  concurrent  reactions  in  each  of  these 
disorders  ;  but  those  described  will  suffice  to  illus- 
trate the  principle. 


IDicious  Circles  in  Disease 


Some  Vicious  Circles  are  specific  in  their  influence, 
others  are  non-specific.  In  the  former  case  the 
primary  disorder  provokes  a  definite  local  reaction 
in  some  organ  or  organs  which  aggravates  the  orig- 
inal disorder  ;  in  the  latter  the  primary  disorder 
merely  lowers  the  power  of  resistance,  which  lowering 
perpetuates  and  intensifies  the  original  condition. 
The  first  group  is  abundantly  illustrated  in  diseases 
of  man  and  the  lower  animals,  while  the  non-specific 
forms  are  widely  prevalent  in  the  vegetable  kingdom. 

Another  classification  might  be  based  on  the 
predominance  of  some  special  factor.  Thus  we 
might  distinguish  between  organic,  mechanical,  in- 
fective, chemical  or  neurotic  Vicious  Circles,  and 
numerous  illustrations  of  each  of  these  forms  will  be 
found  in  the  following  pages. 

A  distinction  may  also  be  drawn  between  Circles 
which  arise  in  the  natural  course  of  disease  and 
those  which  are  artefacts,  i.e.  dependent  on  social 
customs  or  injudicious  treatment.  It  will  be  suffi- 
cient in  this  place  merely  to  indicate  such  an  aspect 
of  the  subject  which  will  be  discussed  in  a  special 
Chapter. 

The  number  of  component  factors  completing  a 
circular  reaction  varies  considerably.  Two  is,  of 
course,  the  minimum,  but  some  writers  have  split 
up  the  morbid  sequence  into  as  many  as  eight  or 
ten  different  components.1 

Classifications,  although  useful  in  clarifying  ideas, 
are  after  all  of  secondary  importance.  Each  reader 
will  adopt  the  system  most  helpful  to  himself. 


1  Halls  Dally  (Medical  Press,  1913,  I.,  p.  222)  illustrates 
a  cardio-gastric  Vicious  Circle  comprising  ten  fac- 
tors ;  Pickerill  (The  Prevention  of  Dental  Caries 
and  Oral  Sepsis,  p.  299)  one  comprising  six  factors. 


Chapter  TTbree 


THE   NERVOUS   SYSTEM 

HE  central  nervous  system  is  the  capital 
of   the   human   microcosm   with   whose 
remotest    outposts    the    capital    is,    for 
good  as  well  as  for  ill,  in  constant  com- 
munication.    In  health  the  closest  corre- 
lations and  polarities  exist  between  it  and  every 
other    organ  ;     in    disease    such    correlations    and 
polarities  are  no  less  intimate. 

The  injurious  circular  reactions  met  with  in  dis- 
orders of  the  nervous  system  are  very  numerous  ; 
fresh  illustrations  are  continually  being  revealed  by 
the  progress  of  research.  All  that  can  be  attempted 
here  is  the  description  of  some  striking  examples, 
which  every  practitioner  will  be  able  to  supplement 
from  his  own  experience. 
We  shall  deal  in  order  with 

I.     Functional  Diseases 
II.     Organic  Diseases 

I.    FUNCTIONAL   DISEASES 

(A)    NEURASTHENIA 

The  commonest  and  most  protean  of  functional 
disorders  is  neurasthenia.  "In  no  complaint  does 
it  happen  more  frequently  that  the  patient  gets 
into  a  Vicious  Circle,  the  fundamental  disorder 
producing  symptoms  which  again  maintain  and 

9 


io  IDfdous  Circles  in  Biseaae 

aggravate  the  disease."1  Owing  to  the  infinite 
variety  of  its  manifestations  neurasthenia  has  been 
described  as  non  morbus,  sed  morborum  cohors,  and 
in  truth  there  is  scarcely  an  organ  or  function  that 
may  not  at  one  time  or  another  be  affected.  In 
this  disease  self-aggravating  factors  are  constantly 
present,  whether  the  psychical  or  physical  functions 
are  involved.2 

This  characteristic  of  neurasthenic  disorders  is 
doubtless  due  to  the  lowering  of  the  neuron  thres- 
hold, owing  to  which  an  increased  response  follows 
a  given  stimulus.  In  other  words  such  a  stimulus 
acts  more  readily  and  more  vigorously  in  a  neuras- 
thenic than  in  a  normal  individual,  and  the  result 
is  a  further  lowering  of  the  threshold. 

It  will  be  convenient  to  deal  first  with  psychical 
and  then  with  physical  disorders,  although  much 
overlapping  is  inevitable. 

(a)    Psychical    Disorders 

Neurasthenia  is  frequently  associated  with  per- 
verted emotivity  and  ideation  (JMatC  II •  a).  These 
perversions  vary  greatly  in  their  manifestations. 
The  following  examples  may  be  briefly  referred  to  : 
irritability,  anxiety,  melancholia,  insomnia.3 


1  Ballet,  Neurasthenia.  Introduction  by  Campbell  Smith, 
p.  xxvi. 

•  Fuller  particulars  will  be  found  in  a  volume  entitled  The 
Vicious  Circles  of  Neurasthenia  and  their  Treatment 
by  J.B.H. 

3  The  psychical  state  in  which  the  individual  is  governed 
by  ideas  or  emotions,  which  more  or  less  persistently 
obtrude  themselves  on  consciousness,  is  frequently 
termed  psychasthenia.  But  there  is  no  definite 
border-line  separating  such  psychical  from  physical 
manifestations,  and  the  condition  will  here  be  in- 
cluded under  the  term  neurasthenia. 


Iftcrvous  System 


ii 


Per*?, 


(a)  NEURASTHENIA 


(b)   HYSTERIA 


(e)  APOPLEXY 


(f)  HYDROCEPHALUS 


plate  ii.— Circles  aseociatcb  with  the 
IRervoue  System. 


12  Dicious  Circles  in  Dieease 

Irritability.  One  of  the  commonest  symptoms 
of  neurasthenia  is  an  exaggerated  irritability,  with 
a  tendency  to  worry  about  trifles  which  would  not 
disturb  the  equanimity  of  a  normal  individual.  vSuch 
irritability  may  be  either  intellectual  or  emotional, 
but  in  either  case  there  is  a  drain  on  the  store  of  ner- 
vous energy  so  that  the  condition  feeds  itself.  In 
some  persons  there  are  unreasonable  explosions  of 
ill-temper,  a  morbid  sensitiveness  to  the  opinion  of 
others,  an  exaggerated  conscientiousness  and  so  on. 
Indeed  the  symptoms  are  infinite  in  variety  and 
degree,  doubtless  also  in  the  tax  they  levy  on  the 
reserve  resources,  and  in  the  exhaustion  they  cause 
of  the  nerve  centres. 

Anxiety.  A  form  of  irritability  which  deserves 
special  mention  reveals  itself  by  various  forms  of 
undue  .anxiety  and  by  the  presence  of  phobias 
which  haunt  the  victim  and  depress  his  vitality. 
Every  phobia,  associated  as  it  is  with  loss  of  self- 
control  and  with  auto-suggestions,  intensifies  its 
own  cause. 

Dubois  describes  the  condition  : 

"  In  neurasthenia  one  must  take  into  account  the 
real  fatigue  of  the  nervous  centres  which,  on  the  one 
hand,  results  directly  from  morbid  states  of  mind,  and, 
on  the  other,  furnishes  new  food  for  auto-suggestions. 
Here  we  have  the  eternal  Vicious  Circle  in  which  the 
neuroses  travel.  Their  real  ills  give  birth  to  their 
fears  and  their  phobias,  and,  on  the  other  hand,  their 
mental  representations  of  a  pessimistic  nature  create 
new  disorders."1 

Spear  also  writes : 

"  The  mental  state  of  the  individual  suffering  from 
neurasthenia  is  also  very  important — these  individuals 
are  usually  depressed,  introspective,  anxious,  appre- 
hensive ;  mental  rest  is  therefore  very  difficult  to 

Psychic  Treatment  of  Nervous  Disorders,  p.   180. 


IRervous  System  13 

obtain.  As  the  unconscious  mental  activity  is  just  as 
exhausting  as,  if  not  more  so,  than  conscious  and 
physical  unrest,  a  Vicious  Circle  is  established  whereby 
the  nervous  system  is  maintained  in  a  state  of 
exhaustion.  It  is  the  presence  of  this  Vicious  Circle 
that  renders  the  establishment  of  a  state  of  complete 
rest  so  difficult  and  consequently  makes  the  cure  of 
this  condition  doubtful  and  sometimes  impossible.1 

These  anxiety  neuroses  are  closely  associated  with 
loss  of  will-power.  Every  effort  may  be  made  to 
exert  and  coax  the  will,  yet  the  result  may  be  utter 
failure  and  the  greater  the  effort  the  less  the  success. 
Indeed  the  very  attempt  to  will  may  annihilate 
will-power.2  Volition  can  also  be  readily  exhausted 
by  the  imagination,  and  the  process  once  started 
continually  reinforces  itself. 

Phobias  are  by  no  means  confined  to  waking 
hours.  In  some  forms  of  neurasthenia,  brought  on 
by  war  conditions,  terrifying  dreams  have  been  a 
prominent  symptom,  associated  with  a  low  blood- 
pressure  and  perpetuating  the  exhaustion  of  the 
neurons.3  Night  terrors  in  children  supply  a  further 
illustration. 

Melancholia.  In  other  cases  neurasthenia  shows 
itself  by  profound  melancholia.  There  is  inveterate 
pessimism,  and  the  depression  further  diminishes 
the  already  reduced  nervous  capital.  Sufferers  fre- 
quently display  a  tendency  to  continual  introspec- 
tion, to  an  exaggeration  of  slight  disappointments, 
and  the  more  they  brood  over  troubles  the  worse 
these  appear,  in  harmony  with  the  well-known 
psychological  law  that  attention  intensifies  sensa- 
tions. 

This  form  of  neurasthenia  may  be  acquired  as  a 

1  A  Manual  of  Nervous  Diseases,  pp.  495,  505. 
"  Dowse,  Neurasthenia,  pp.  28,  30. 
3  Lancet,  1917,  II.,  p.  456. 


14  liMcious  Circles  in  Disease 

result  of  shock  or  accident,  especially  if  litigation 
is  probable.  The  trauma  may  appear  to  be  insigni- 
ficant, and  yet  the  resulting  neurosis  completely 
transforms  the  outlook  on  life  owing  to  the  deep 
mental  impression  made  by  the  shock.  In  some 
cases  mischief  is  done  through  the  interaction  be- 
tween the  mind  of  the  patient  and  that  of  his 
physician  or  solicitor,  i.e.  through  hetero-suggestion. 

Thorburn  writes  : 

"  The  patient  has  often  heard  that  after  the  shock 
of,  let  us  say,  a  railway  accident,  symptoms  are  liable 
to  be  progressive,  to  develop  at  remote  periods  and  to 
endure  indefinitely.  In  this  condition  of  expectation  of 
disaster  he  consults  probably  both  his  medical  and  his 
legal  advisers.  The  former  has  often  a  limited  experi- 
ence of  traumatic  neuroses  ;  he  knows  that  his  patient 
is  and  always  has  been  an  honest  man  ;  he  may  have 
doubts  in  his  own  mind  as  to  whether  organic  disease 
of  the  nervous  system  does  not  follow  shock.  In  any 
event,  he  enters  upon  his  task  of  relief  and  encourage- 
ment with  a  more  serious  aspect  than  he  would  otherwise 
assume,  he  takes  careful  note  of  all  minor  symptoms, 
and  he  probably  has  to  write  reports  to  the  solicitor, 
which  he  is  asked  to  make  '  as  strong  as  possible.' 
The  solicitor  is  an  even  graver  danger  ;  it  is  his  pro- 
fessional duty  to  obtain  the  largest  possible  amount 
of  compensation  for  his  client,  and  in  so  doing  to 
emphasize  to  the  utmost  any  loss,  inconvenience  or 
suffering  which  the  latter  may  have  sustained,  and 
especially  to  guard  against  the  making  of  any  settle- 
ment before  all  possible  future  inconveniences  have 
been  excluded.  None  of  the  people  thus  concerned 
have  any  intention  to  exaggerate,  but  each  mind  reacts 
upon  the  other,  and  we  have  established  a  complete 
Vicious  Circle  as  a  result  of  which  the  unfortunate 
patient  tends  to  grow  daily  worse."1 

lProc.  Royal  S.  of  Med.  (1914),  VII.  (ii.),  (Neurological 
Section),  p.  8.  Cf.  also  Bailey,  Diseases  of  the 
Nervous  System  in  Cases  of  Accident,  p.  434. 


1Ren>ou0  System  15 

Insomnia.  Insomnia  frequently  complicates 
neurasthenia  and  is,  in  Clifford  Allbutt's  words, 
"  generally  one  of  the  links  in  the  Vicious  Circle  in 
which  the  victim  is  enchained."1  Such  sleeplessness 
results  from  over-excitability  of  the  cerebral  cortex, 
from  a  lowering  of  the  neuron  threshold  which 
enables  stimuli,  which  would  be  subliminal  in  normal 
individuals,  to  affect  consciousness.  Insomnia  in  its 
turn  prevents  the  renewal  of  those  substances  which 
are  used  up  by  the  discharge  of  energy  and  thus 
perpetuates  itself.  Again  conditions  which  interfere 
with  the  repose  of  those  brain  cells  which  are  the 
organs  of  conscious  thought  may  keep  in  operation 
the  processes  of  ideation,  with  which  is  necessarily 
associated  some  cerebral  hypersemia.  Ideation  and 
hypersemia  then  react  one  on  the  other  and  form  a 
sequence  of  events  that  torments  the  neuropath.2 

Insomnia  may  also  be  due  to  excessive  fatigue, 
to  an  exhaustion  of  the  nerve  centres  which  arrests 
the  progress  of  repair.  Such  a  condition  is  readily 
provoked  in  neurasthenics  owing  to  their  lower 
reserves  of  potential  energy.  The  insomnia  hinders 
recuperation  and  acts  as  a  malignant  abettor.3 
Habitual  sleeplessness  is  not  uncommonly  due  to  the 
cerebral  neurons  or  vessels  failing  to  resume  their 
rhythmical  quiescence  at  bed-time.  The  more  the 
sufferer  tries  to  sleep  the  less  his  success.  In- 
somnia and  the  dread  of  it  react  upon  and  aggravate 
each  other.  Job  evidently  was  a  bad  sleeper  : 

"  When  I  lie  down  I  say  ;    When  shall  I  arise  and 

the  night  be  gone  ?     And  I  am  full  of  tossings  to  and 

fro  unto  the  dawning  of  the  day."4 

1  Allbutt  and  Rolleston,  System  of  Medicine,  VIII.,  p.  750. 

2  Sawyer,  Insomnia,  its  Cause  and  Cure,  pp.  26,  27.      Cf. 

also  Saleeby,  Worry,  the  Disease  of  the  Age,  passim. 
'Garrett  Anderson,  Encyclopedia  Medica,  VIII.,  p.  336. 
4  Ch.  VII.,  4. 


16  IDicious  Circles  in  Disease 

In  many  cases  an  accumulation  of  toxins  may 
be  both  cause  and  effect  of  the  sleeplessness. 

Amongst  other  psychical  manifestations  may  be 
mentioned  vertigo,1  anorexia,  and  an  exaggerated 
proclivity  to  the  repression  of  painful  memories.2 
All  of  these  may  perpetuate  the  neurosis. 

Several  forms  of  psychical  disorder  are  usually 
present  simultaneously  and  the  mischievous  influence 
is  then  cumulative.  In  severe  cases  all  the  above- 
mentioned  disorders  may  combine  to  reduce  the 
sufferer  to  the  direst  misery. 

(b)   Physical  Disorders 

In  most  cases  of  neurasthenia  local  symptoms 
are  present  which  feed  the  neurosis  and  perpetuate 
the  disorder.  Owing  to  the  lowered  neuron  thres- 
hold peripheral  impulses  which  would  not  affect 
consciousness  in  health  evoke  uncomfortable  or 
even  painful  sensations.  These  disturb  ideation  and 
emotivity  and  arouse  injurious  auto-suggestions.  The 
direction  of  consciousness  aggravates  the  trouble, 
since  attention  intensifies  sensation. 

This  general  principle  is  thus  stated  by  Krafft- 
Ebing  : 

"  A  true  Vicious  Circle  is  gradually  developed  in 
neurasthenia,  in  consequence  of  the  morbid  relations 
between  the  psychic  and  the  somatic  functions.  A 
crowd  of  functional  disorders  are  projected  by  the 
psychic  condition  into  the  extracephalic  organs,  and 
these  in  their  turn  react  on  the  psychic  condition,  more 
especially  on  the  emotions."3 


1  Bing,  Text-Book  of  Nervous  Diseases,  p.  411. 

-  Rivers,  The  Repression  of  War  Experience  Lancet  1018 
L,  p.  173. 

3  Nothnagel,  Specielle  Pathologic  und  Therapie,  Nervositat 
und  Neurasthenische  Zustande,  p.  71.  Cf.  also 
Babinski  and  Froment,  Hysteria  or  Pithiatism,  p.  65. 


IRervous  System  17 

These  physical  or  somatic  disorders  present  a 
great  variety  in  form  and  severity  ;  but  as  a  rule 
the  sufferer  tends  to  magnify  a  molehill  into  a 
mountain  and  adheres  obstinately  to  his  erroneous 
perspective. 

It  is  not  necessary  to  discuss  these  local  dis- 
orders in  any  great  detail  since  this  has  already 
been  attempted  in  another  volume  ;*  but  the  pic- 
ture would  be  incomplete  without  some  reference 
to  the  more  important  local  reactions.  These  are 
not,  as  a  rule,  limited  by  hard  and  fast  lines.  The 
interlocking  gears  are  so  complex  that  disorder 
awakens  echoes  in  all  directions  with  endless 
secondary  reverberations.  The  following  examples 
must  merely  be  regarded  as  typical  of  many  others. 

Cardiac  Neuroses.  No  functional  disorders 
arouse  greater  anxiety  than  those  connected  with 
the  heart.  Even  when  trivial  in  themselves  they 
may  arouse  a  confident  belief  in  a  speedy  exitus. 
Imaginary  heart  disease  is  said  to  be  even  commoner 
than  organic  heart  disease,  and  supplies  a  good 
illustration  of  how  the  dread  of  a  disease  may  pro- 
voke corresponding  subjective  sensations. 

The  sequence  of  events  is  somewhat  as  follows  : 
the  fear  of  heart  disease  awakens  auto-suggested  sen- 
sations in  the  cardiac  region  producing  tachycardia, 
extra-systoles  with  palpitation,  and  an  intermittent 
pulse.  The  associated  sensations  then  arouse  distress 
and  terror,  which  in  their  turn  further  disturb  the 
cardiac  action. 

Such  attacks  are  especially  common  at  night  and 
may  be  caused  by  nightmare,  reducing  the  neura- 
sthenic person  to  a  condition  of  utter  misery.  Even 
fatal  syncope  may  result. 


xThe  Vicious  Circles  of  Neurasthenia  and  their  Treatment, 
by  J.B.H. 


i8  IDidous  Circles  in  2>ieea0e 

Andre-Thomas  describes  the  condition  : 

"  Not  only  may  neurasthenia  give  rise  to  cardiac 
disorders  and  anxieties,  but  cardiac  anxieties  may 

also  give  rise  to  neurasthenia Emotions,  kept 

alive  by  fear,  aggravate  the  symptoms  or  create  fresh 
ones.  Thus  the  patient  becomes  involved  in  a  Vicious 
Circle  which  persists  until  he  can  be  convinced  that 
there  is  nothing  amiss  with  his  heart."1 

Dubois  draws  attention  to  the  same  correlations 
and  points  out  that  the  expression  "  spiral  "  is  in 
many  respects  preferable  to  "  circle,"  since  it  more 
clearly  conveys  the  idea  of  an  ingravescent  condi- 
tion : 

"  The  patient  may  attribute  the  beginning  of  his 
illness  to  some  psychic  disorder,  such  as  an  imaginary 
evil  that  worries  and  frightens  him.  Or,  conversely, 
he  may  attribute  his  trouble  to  some  emotion  due  to 
his  local  disorder.  In  either  case  his  illness  works  in 
a  Vicious  Circle  or  rather  in  a  spiral.  The  local  trouble 
that  bothers  him  arouses  hypochondriacal  ideas  and 
causes  distress,  followed  by  palpitation  and  gastro- 
intestinal dyspepsia  which  in  their  turn  create  phobias. 
These  fresh  disturbances  then  provoke  other  functional 
disorders  or  aggravate  the  existing  ones.  Hence  a 
fresh  source  of  phobias  which  drive  the  victim  further 
along  the  spiral."2 

Cardiopaths  are  frequently  met  with  in  whom  the 
erroneous  belief  that  they  have  heart  disease  excites 
an  ever-present  dread  of  illness  or  immediate  death. 
The  constant  direction  of  the  mind  to  the  imaginary 
lesion  then  leads  to  a  morbid  consciousness  of  trivial 
sensations  and  to  such  an  unwholesome  regime  as 
actually  to  make  the  heart  feeble  and  flabby,  so 

1  Psychotherapie,  pp.  229,  230.  Cf.  also  Lewandowsky, 
Handbuch  der  Neurologic,  V.  (iv.),  p.  40.  Clinical 
Lectures  by  German  Authors  (N.S.S.),  (1894),  p.  69. 
Practitioner,  1918,  I.,  pp.  179,'  186,  188. 

-  Volkmann,  Sammlung  Klinischer  Vortrage  (Innere  Medizin, 
Nos.  137-166),  1907-1909,  p.  520. 


IRervcms  Spetem  19 

that  at  the  slightest  provocation  it  reacts  on  the 
neurotic  condition.  The  exaggerated  fears,  like  the 
sword  of  Damocles,  over-shadow  life  and  render 
all  enjoyment  impossible.  Such  obsessions  are 
amongst  the  commonest  complications  of  neuras- 
thenia. 

Mott  thus  describes  them  : 

"  Any  organ  or  structure  which  naturally  or  by 
habit  performs  its  functions  automatically  becomes 
disordered  in  its  functions  when  there  is  mental  appre- 
hension and  preoccupation  regarding  the  performance 
of  that  function.  Hence  we  can  understand  how  a 
continued  preoccupation  regarding  the  function  of  an 
organ  like  the  heart  or  stomach,  or  indeed  any  organ 
of  the  body,  of  the  perfect  action  of  which  we 
should  be  quite  unconscious,  becomes  an  obsession,  for 
disordered  function  tends  to  repercussion  in  the  field 
of  consciousness,  causing  a  continual  conflict  between 
reason  and  emotion  for  re-adjustment.  Thus  a  Vicious 
Circle  is  liable  to  be  established  owing  to  the  inherent 
state  of  emotivity  of  the  neurasthenic."1 

Other  cardiac  neuroses  are   described   on  p.  53. 

Gastric  Neuroses.  The  correlations  existing 
between  the  nervous  and  the  digestive  systems  are 
so  intimate  that  disorder  in  the  one  readily  provokes 
disorder  in  the  other.  Their  importance  has  been 
emphasised  by  Mathieu  and  Roux  : 

"  There  is  in  these  cases  an  interlocking  system  of 
Vicious  Circles  with  which  the  physician  must  be 
familiar  if  he  wishes  to  understand  the  mechanism  of 
the  diseased  organism,  and  if  he  wishes  his  treatment 
to  be  rational  and  useful."2 

Since  the  various  regions  of  the  gastro-intestinal 

1  Lancet,  1918,  I.,  p.  128. 

"  I,es  Cercles  Vicieux  dans  la  Pathologic  Gastro-Intest- 
inale,"  Pathologic  Gastro-Intestinale.  Series  I.  (1909), 
p.  147. 


20  IDidous  Circles  in  2>isea0e 

tract  have  been  discussed  in  detail  in  another  volume, 
we  may  content  ourselves  with  three  examples. 

Atonic  dyspepsia  is  one  of  the  commonest  physical 
disorders  in  the  neuropath,  cause  and  effect  abetting 
each  other. 

Cramer  writes  : 

"  Not  only  do  the  nervous  disorders  provoke  neurotic 
dyspepsia,  but  in  its  turn  the  neurotic  dyspepsia 
intensifies  the  nervous  disorder."1 

Auto-suggestions  are  also  very  prevalent  and  may 
play  almost  as  great  a  part  as  in  cardiac  neuroses. 
Ceaseless  preoccupation  with  the  state  of  the  stomach 
brings  gloom  and  discouragement  which  perpetuate 
the  hypochondriasis. 

Membranous  colitis  is  another  disorder  in  which 
the  local  and  central  conditions  reciprocally  maintain 
each  other. 

Mathieu  writes  : 

"  In  cases  of  muco-membranous  colitis  ...  a  true 
Vicious  Circle  appears  often  to  be  present.  The  neura- 
sthenia and  the  colitis  react  on  and  aggravate  each 
other."2 

And  again  : 

"  The  colitis,  the  pain  and  the  nutritive  disorders 
create  and  perpetuate  the  neurasthenia.  The  neura- 
sthenia in  its  turn  aggravates  the  colitis.  A  Vicious 
Circle  is  present." 

A  third  example  is  presented  by  constipation, 
frequently  both  effect  and  cause  of  neurasthenia. 
The  exhaustion  of  the  nervous  system  shows  itself' 
in  sluggish  peristalsis,  and  the  resulting  coprostasis 
in  its  turn  depreciates  the  functions  of  the  nervous 
system. 

1Nervositat,   p.    197.      Cf.    also   Saleeby,   Worry,  the  Dis- 
ease of  the  Age,  p.  130. 

2Traite  des  Maladies  de  l'Estomac  et  de  1'Intestin,  pp.  288 
304- 


IRervoue  System  21 

Striimpell  writes  : 

"  Habitual  constipation  is  frequently  associated  with 
neurasthenia,  but  the  nature  of  this  association  is 
probably  not  the  same  in  every  case.  Often  neura- 
sthenia and  constipation  seem  to  be  co-ordinate  sym- 
ptoms ;  sometimes  existing  constipation  has  an  un- 
favourable effect  upon  the  psychical  condition  of 
patients,  rendering  them  feeble,  fretful,  out  of  sorts 
and  nervous.  As  a  rule,  however,  neurasthenia  is  the 
primary  disease,  and  the  irregularity  of  the  bowels 
appears  as  a  result  of  abnormal  nervous  influences  or 
secondary  conditions.  Often  the  two  states  act  in  a 
Vicious  Circle,  each  sustaining  and  aggravating  the 
other."1 

In  other  cases  of  neurosis  there  may  be  hyper- 
peristalsis  and  diarrhoea,  which  in  turn  keep  up  a 
state  of  obsession.  The  more  the  neuropath  dreads 
an  attack  of  diarrhoea  the  more  likely  is  it  to  occur, 
and  vice  versa. 

Gant  writes  : 

"  Stimuli  responsible  for  diarrhoea  may  be  induced 
by  psychic  emotions,  disease  of  the  brain,  cord,  general 
or  local  nerve  mechanism,  inflammation,  ulceration, 
neoplasms,  strictures  of  foreign  bodies  in  the  intestine, 
or  lesions  affecting  it  from  without,  or  anything  which 
irritates  the  intestinal  nerve-ganglia. 

Occasionally,  multiple  or  widely  varying  stimuli 
work  simultaneously,  so  that  a  Vicious  Circle  is  estab- 
lished, under  which  circumstances  there  is  exaggerated 
intestinal  motility,  and  the  patient  suffers  deplorably 
from  diarrhoea  extremelv  difficult  to  relieve  or  cure."2 


1  Text-Book  of  Medicine,  I.,  p.  611.  Cf.  also  The  Vicious 
Circles  of  Habitual  Constipation,  by  J.B.H.,  Prac- 
titioner, 1915,  II.,  p.  560. 

2Diarrheal,  Inflammatory,  Obstructive  and  Parasitic  Dis- 
eases, p.  18.  Cf.  also  Matthieu  and  Roux,  Pathologic 
Gastro-Intestinale,  Series  III.  (1911),  pp.  208,  230. 


22  IDidoue  Circles  in  Disease 

Sexual  Neuroses.  There  are  numerous  circular 
reactions  between  the  nervous  and  the  sexual 
systems,  primary  and  secondary  factors  reinforcing 
each  other.  This  applies  to  the  entire  sexual  tract, 
every  region  of  which  is  closely  linked  with  the 
central  nerve  centres.  The  weakening  of  self- 
control  so  common  in  neurasthenia  only  too  often 
leads  to  excessive  self-indulgence  which  intensifies 
the  weakness.  Inmates  of  lunatic  asylums  often 
present  lamentable  results  of  such  indulgence  which 
is  often  incurable,  especially  where  there  are  in- 
herited neuropathic  tendencies. 
Miiller  writes  : 

"  In  neurasthenic  persons  of  both  sexes,  especially 
if  unmarried,  there  is  a  tendency  to  satisfy  the  sexual 
instinct  by  means  of  masturbation.  Indeed  it  is  often 
difficult  to  decide  whether  the  masturbation  should 
be  regarded  as  a  result  or  as  a  cause  of  the  sexual 
neurasthenia,  since  a  Vicious  Circle  has  generally  been 
established."1 

Again  in  sensitive,  highly  strung  women,  morbid 

correlations   are   frequently   set   up   by   uterine   or 

ovarian  congestion  or  pain.     The  nervous  system 

and  the  local  disorders  act  and  react  on  each  other. 

As  Amand  Routh  says  : 

"  We  have  frequently  to  deal  with  a  Vicious  Circle, 

with  local  and  constitutional  states  so  interacting  that 

no  real  improvement  is  possible  until  both  the  general 

and  local  states  receive  their  due  share  of  attention."2 

Herman  and  Maxwell  also  write  : 

"  In  chronic  pelvic  pain  with  neurasthenia  effects 
follow  one  another  in  a  Vicious  Circle.  The  patient 
feels  more  severely  the  pelvic  pain  because  her  nervous 
system  is  too  sensitive.  The  persistent  pelvic  pain 

1  Neurasthenic,  p.  181.     Cf.  also  Hiihner,  Diseases  of  the 

Sexual  Function,  pp.  4,  15,  161,  183. 

2  Allbutt,  Playfair  and  Eden,  Gynaecology,  p.  737. 


IRervous  System  23 

keeps  her    nervous   system    weak    and   sensitive    and 
further  weakens  it."1 

Such  uterine  and  ovarian  pain  is  a  good  illustration 
of  the  general  relation  of  pain  to  a  hypersesthesia 
of  the  nervous  system.  Bach  factor  intensifies  the 
other  and  the  process  has  much  to  do  with  the 
invalidism  so  often  met  with  in  highly-strung  women. 
If  sleeplessness  is  super  added  the  symptom-complex 
is  even  more  difficult  to  deal  with. 

The  same  inter-dependences  apply  mutatis  mutan- 
dis to  neuralgia  and  nervous  headache. 

Herman  has  well  described  the  condition  : 

"  The  great  causes  of  neurasthenia  are  conditions 
which  (a)  cause  continuous  pain  and  (b)  prevent  sleep. 
The  two  things  often  form  a  Vicious  Circle.  A  small 
local  cause  disturbs  sleep,  and  want  of  sleep  makes 
the  nervous  system  over-sensitive.  In  proportion  as 
the  neurasthenic  symptoms  have  coincided  in  time 
with  the  development  of  local  pain,  so  surely  may  we 
conclude  that  the  removal  of  the  local  pain  and  the 
procuring  of  sound  sleep  will  cure  the  neurasthenia."2 

Many  other  illustrations  of  somatic  neuroses  might 
be  given,  did  space  permit  ;  but  enough  has  been 
said  to  indicate  the  facile  creation  of  Circles  where 
the  neuron  threshold  has  been  lowered  in  neura- 
sthenia. Such  reciprocal  correlations  indeed  play 
a  great  part  in  the  psychology  of  modern  life. 

(B)    OTHER   FUNCTIONAL   DISORDERS 

Hysteria.  Hysteria  differs  mainly  from  neura- 
sthenia by  the  presence  of  an  abnormal  mentality 
which  shows  itself  in  increased  suggestibility  and 
emotional  instability,  combined  with  lowered  powers 
of  inhibition.  In  many  cases  some  disappointment  or 
other  source  of  psychical  distress  has  been  repressed 

1  Diseases  of  Women,  p.  73. 

2 British  Med.  /.,  1910,  I.,  p.  183. 


24  IDicious  Circles  in  Disease 

and  disappears  from  consciousness.  Yet  the  repressed 
ideas  remain  latent  and  may  break  out  in  some  form 
of  mental  or  physical  reaction  which  perpetuates 
the  primary  instability.1 

A  striking  disorder  which  is  not  uncommon  in 
hysterical  women  is  that  known  as  anorexia  nervosa 
to  which  attention  was  drawn  by  Gull  and  Weir 
Mitchell  (platC  II.  b).  The  condition  may  originate 
in  some  perversion  of  appetite  or  in  a  fear  of  growing 
fat  or  in  some  minor  ailment  which  suggests  the 
idea  of  illness  and  an  inability  to  take  food.2  This 
is  accompanied  by  an  actual  loss  of  appetite  or  even 
a  refusal  to  be  tempted  to  eat,  and  results  in  general 
emaciation.  The  neurosis  tends  to  starvation  ; 
the  starvation  feeds  the  neurosis.  The  nervous 
system  is  profoundly  affected,  the  blood  is  impover- 
ished and  the  psychical  functions  disordered.  As  a 
result  the  sufferer  becomes  a  bed-ridden  querulous 
invalid,  a  burden  to  her  family.  In  course  of  time 
the  malnutrition  reduces  the  body  to  a  bag  of  little 
more  than  skin  and  bones,  and  a  fatal  issue  often 
closes  the  scene. 

Schofield  writes  as  follows  : 

"  A  Vicious  Circle  is  often  kept  up  in  these  cases 
which  it  is  absolutely  essential  to  break.  They  begin, 
it  may  be,  with  loss  of  appetite  from  some  slight  cause . 
This  .  .  .  leads  to  disordered  thoughts  and  the  idea 
of  disease  is  started.  This,  again,  makes  the  appetite 
still  more  capricious  ;  the  thoughts  therefore  get  still 
worse,  and  so  the  body  starves  the  brain  and  the  brain 

1  Spear,  Manual  of  Nervous  Diseases,  p.  472. 

2  The  opposite  conditions  to  those  described  in  this  Section 

establish    physiological    or   virtuous    Circles circuli 

virtuosi — of  which  a  large  number  are  in  constant 
operation  in  the  normal  body.  Good  nutrition, 
sleep,  exercise,  cheerfulness  of  disposition  are  all 
closely  dependent  on  each  other. 


1Ren>ou0  patent  25 

starves  the  body  ;  and  the  emaciated  patient  having, 
probably  enough,  first  worn  out  her  friends,  sinks  at 
last  into  her  grave  from  sheer  starvation.  I  have  seen 
such  deaths."1 

Rayner  has  also  described  the  process  : 

"  In  diseased  conditions,  especially  in  the  depressed 
emotional  states,  this  interaction  of  the  mind  on  the 
body  and  of  the  bodily  state  on  the  brain  establishes 
a  Vicious  Cycle  of  nutritional  disorder,  which  tends  to 
increase  and  prolong  the  disease."2 

Migraine.  The  pathology  of  the  functional 
disorder  known  as  migraine  or  hemicrania  is  still 
obscure,  some  neurologists  attributing  it  to  a  form 
of  nerve-storm,  others  to  a  spasm  or  relaxation  of 
the  smaller  arteries  or  veins,  others  to  toxaemia, 
others  to  increased  pressure  in  the  ventricles  of  the 
brain,  associated  with  stenosis  of  the  foramen  of 
Monro. 

If  the  latter  hypothesis  is  correct,  a  self -perpetu- 
ating condition  is  probably  present  which  is  thus 
described  by  Jeliffe  : 

"  The  occasional  causing  of  a  passive  or  active 
hypersemia  of  the  brain  leads  to  hyperaemia  of  the 
choroid  plexus.  This  causes  a  more  or  less  complete 
plugging  of  the  foramen  of  Monro,  with  increase  of 
pressure  in  one  or  both  of  the  ventricles.  The  increased 
pressure  on  the  vessels  causes  more  distention  and  more 
pressure  on  the  walls  of  the  ventricles  ;  a  Vicious 
Cycle  established  and  the  migraine  mounts  to  its  height, 
until  the  pressure  is  relieved,  either  by  a  spontaneous 
reduction  or  by  the  sudden  let-down  in  tension  due  to 

Serves  in  Disorder,  p.  162. 

2Allbutt  and  Rolleston,  System  of  Medicine,  VIII.,  p.  965. 
Dr.  Rayner  and  other  writers  substitute  "  Vicious 
Cycle"  for  "Vicious  Circle."  The  latter  term  seems 
preferable  as  implying  continuity  as  opposed  to 
recurrence. 


26  tDicious  Circles  in  Disease 

a  shock  reaction— such  as  occurs  in  the  act^of  vomiting, 
from  the  use  of  various  vaso-dilators,  etc."1 
On  the  other  hand  Adami  believes  the  cause  to 

lie  in  a  paradoxical  contraction  of  arteries  which 

also  creates  a  circular  reaction. 

Adami  writes  : 

"  The  higher  the  blood  pressure,  the  greater  becomes 
the  contraction  of  the  arterioles  ;  the  less,  therefore, 
the  blood  supply  to  the  tissues  and  the  greater  the  call 
upon  the  central  nervous  system  for  more  blood. 
Whether  from  reflex  stimulation  of  the  heart  to  increased 
activity  in  order  to  supply  the  tissues,  or  from  direct 
automatic  action  of  the  increased  aortic  pressure  in 
raising  the  intraventricular  pressure,  and  so  stimulating 
the  ventricles  to  more  forcible  contraction,  the  blood 
pressure  becomes  yet  higher,  and,  as  a  result,  the 
arteries  still  further  contracted.  It  is  along  these  lines 
that  we  would  explain  the  progressive  rise  of  blood 
pressure  and  contraction  of  the  smaller  arteries  in 
migraine."2 

Further  research  is  necessary  before  the  pathology 
can  be  regarded  as  settled. 

Shock.  Under  this  term  may  be  included  various 
conditions  such  as  fainting  or  syncope  in  which 
there  is  loss  of  vaso-motor  control  (plate  H.  c). 
There  may  be  a  variety  of  causes  including  the 
administration  of  an  anaesthetic,  concussion,  strong 
emotion,  haemorrhage  etc.  During  health  the  activ- 
ity of  the  vaso-motor  centres  is  increased  or  dimin- 
ished, according  as  arterial  pressure  falls  or  rises, 
the  cerebral  circulation  being  maintained  by  this 
compensatory  mechanism.  But  when  this  centre 
is  paralysed,  exhausted  or  inhibited  by  fear  or  other 
cause,  the  vaso-motor  mechanism  is  thrown  out  of 

1  Osier  and  Macrae,  System  of  Medicine,  V.,  p.  710.     Cf. 

also  Spitzner,  Ueber  Migraine,  p.  76. 

2  Principles  of  Pathology,  II.,  p.  175. 


1Ren>ous  System  27 

gear,  and  is  weakened  instead  of  stimulated  by  a 
diminished  blood-supply.  In  severe  cases  the  blood- 
pressure  falls  so  much  as  partially  to  empty  the 
intrinsic  cardiac  and  cerebral  vessels.  Less  blood 
is  pumped  up  to  the  brain,  and  the  bulbar  centre 
is  still  further  weakened.1  The  cardiac  anaemia 
may  also  cause  enfeeblement  and  dilation  of  the 
heart,  and  thus  further  interfere  with  the  compen- 
satory mechanism.  Attacks  of  fainting  are  due  to 
a  like  interference  with  the  vaso-motor  mechanism. 
Every  faint  renders  the  bulbar  centres  which  are 
largely  controlled  by  self-consciousness  more  liable 
to  loss  of  control  over  blood-pressure. 

Paroxysmal  Neuroses.  Rhythm  plays  a  part  of 
great  importance  in  physiological  processes,  as  is 
shown  by  the  periodicity  in  the  functions  of  the 
heart,  the  lungs,  the  intestines,  the  ovaries,  the 
brain  and  so  forth.  There  is  economy  of  energy  in 
such  a  mechanism  since  one  stimulus  does  the  work 
of  many.2 

Such  a  fundamental  biological  principle  finds  cor- 
responding expression  in  pathology,  as  may  be 
illustrated  by  various  paroxysmal  neuroses.  In 
such  there  is  often  an  increasing  proclivity  to  par- 
oxysm which  may  be  acquired  through  mere  repeti- 
tion. Bach  attack  from  being  at  first  an  effect 


,  British  Med.  /.,  1910,  II.,  p.  759.  Cf.  also  Practi- 
tioner, 1910,  II.,  p.  169.  Although  this  explanation 
is  the  one  usually  accepted,  pathologists  doubt  its 
sufficiency,  since  the  vaso-motor  centre  is  by  no  mean 
always  exhausted  in  shock,  and  the  general  and 
visceral  arteries  may  be  found  contracted  instead  of 
dilated.  The  question  is  still  sub  judice.  British 
J.  of  Surgery,  I.,  p.  114. 

2  An  excellent  account  of  rhythm  in  biology  is  given  by 
Gilford,  Disorders  of  Post-Natal  Growth  and  Develop- 
ment, pp.  112,  123. 


28  IDictous  Circles  in  Disease 

becomes  in  turn  a  cause.  Epilepsy  supplies  a  good 
example  (plate  II.  d).  Every  fit  increases  the 
labile  condition  of  the  nerve  centres  and  facilitates 
recurrence.  Hence  the  best  treatment  is  to  break 
the  habit. 

The  rhythm  associated  with  the  status  epilepticus 
may  establish  other  circular  reactions  through  the 
increasing  venosity  of  the  blood  caused  by  inter- 
ference with  the  respiration.  Such  venosity  may  be 
due  to  the  convulsions  and  perpetuate  them  until 
death  closes  the  scene. 

A  similar  condition  may  arise  from  the  prolonged 
convulsions  which  sometimes  occur  in  general  para- 
lysis. In  both  these  disorders  there  are  mechanical 
conditions  which,  as  Mott  points  out,  produce  a 
Vicious  Circle  terminating  in  progressively  increased 
venosity  of  the  blood  in  the  cortex,  especially  of  that 
portion  supplied  by  the  carotid  arteries.1 

Allied  to  epileptic  attacks  are  various  forms  of 
tic  and  habit  spasms,  which  often  persist  long  after 
the  cause  has  been  removed.  They  were  attributed 
by  Hunter  to  the  "memory  of  the  body."  The  attempt 
to  restrain  a  habit  spasm  may  be  accompanied  by  a 
distinct  mental  distress,  and  great  relief  is  felt  when 
the  rhythmic  discharge  has  occurred.  To  the  same 
group  belong  the  neuroses  of  blushing  and  stutter- 
ing. 

Vices  of  all  kinds  beget  a  craving  which  favours 
further  indulgence. 

The  familiar  form  of  insanity  known  as  "  folie 
circulaire"  also  shows  a  strong  tendency  to  rhythm, 
which  tendency  is  apt  to  grow  habitual  and  show 
itself  on  easier  provocation.  The  initial  depression 
passes  through  exhaustion  into  mania  which  pro- 
duces toxsemia  and  reappears  as  depression. 


1Allbutt  and  Rolleston,  System  of  Medicine,  VII.,  p.  226. 
Cf.  also  Archives  of  Neurology,  I.,  p.  502. 


IRervous  System  29 

Paralysis  of  Thermotaxis.  An  interesting 
sequence  of  events  may  result  from  a  weakening  or 
paralysis  of  the  thermotaxic  mechanism,  such  as  may 
follow  a  dangerously  high  or  low  temperature. 
For  example,  pyrexia  may  paralyse  that  mechanism, 
as  a  result  of  which  the  temperature  of  the  body 
may  rise  to  a  fatal  level.  One  of  the  commonest 
causes  of  such  hyperpyrexia  is  rheumatic  fever, 
in  reference  to  which  W.  S.  Church  writes  : 

"  In  whatsoever  way  the  paralysis  of  the  heat- 
regulating  centres  is  produced,  a  Vicious  Circle  is  set 
up,  resulting  in  an  over-heated  condition  of  the  body, 
and  a  consequent  deterioration  of  tissue,  the  muscular 
tissue  of  the  heart  especially  suffering."1 

Prolonged  exposure  to  cold  illustrates  the  opposite 
condition. 

Coma-  Coma  is  often  due  to  a  high  intra-cranial 
pressure  and  tends  to  keep  up  that  pressure  through 
the  associated  respiratory  embarrassment.  Owing 
to  the  lowering  or  abolition  of  the  reflexes,  saliva, 
food  and  drink  often  collect  in  the  trachea,  and, 
not  being  expelled  by  reflex  cough,  hamper  respira- 
tion and  cause  venous  engorgement,  circumstances 
which  aggravate  the  already  high  intra-cranial 
pressure. 

II.     ORGANIC   DISEASES 

Organic  diseases  of  the  nervous  system  present 
some  circular  reactions  of  great  clinical  importance, 
several  of  which  may  terminate  fatally. 

Cerebral  Haemorrhage.  Under  healthy  con- 
ditions there  is  an  enormous  difference  between  the 
blood-pressure  in  the  cerebral  arteries  (ca.izo  mm.Hg) 
and  the  intra-cranial  pressure  (ca.  venous  pressure, 
i.e.  little  above  zero).  Cerebral  haemorrhage,  how- 
ever, tends  to  raise  the  intra-cranial  pressure  to  a 

1  Allbutt  and  Rolleston,  System  of  Medicine,  II.  (i.),  p.  627. 


30  IDicious  Circles  in  Disease 

level  approximating  to  arterial  pressure,  and  thus 
squeezes  the  blood  out  of  the  vaso-motor  centres, 
so  as  to  render  them  anaemic  (plate  II.  e).  In 
their  urgent  need  for  blood  these  centres  respond  by 
effecting  a  splanchnic  vaso-motor  constriction,  so 
great  at  times  as  to  raise  the  arterial  pressure  to  as 
high  as  400  mm.  Hg  or  more. 

The  irony  of  the  situation  thus  produced  is  that 
the  rise,  so  beneficent  in  one  respect,  is  apt  to  prove 
disastrous  by  starting  the  haemorrhage  afresh  or 
by  increasing  the  flow.  A  further  rise  of  intra- 
cranial  pressure  then  results,  and  the  whole  sequence 
is  repeated.1 

Cerebral  haemorrhage  frequently  proves  fatal  by 
pressure  on  the  respiratory  centre.  If  the  patient 
survives  the  danger  of  respiratory  paralysis,  a 
further  complication  may  arise  and  increase  the 
haemorrhage.  As  the  diffused  blood  lacerates  the  soft 
brain  tissues,  an  enlarging  cavity  is  formed  which 
is  filled  with  blood  at  nearly  arterial  pressure.  The 
larger  such  a  cavity  grows  the  greater  is  the  pres- 
sure exerted  by  the  blood,  on  the  principle  of  the 
hydraulic  press,  while  conversely  the  greater  the 
pressure  the  more  does  the  cavity  enlarge.  In  fact 
it  is  difficult  to  see  how  haemorrhage  into  the  brain 
ever  ceases,  unless  by  pressure  on  the  artery  itself. 

If  the  high  pressure  persists  for  any  considerable 
time,  further  correlations  are  established .  The  vaso- 
motor  centre  becomes  exhausted  and  loses  its  grasp 
over  the  splanchnic  area,  which  fills  with  blood. 
Hence  results  cerebral  and  cardiac  anaemia,  which 
leads  to  further  exhaustion  of  the  centre.2 

Hydrocephalus.      The  progressive  development 

^aneway,  Clinical  Study  of  Blood-pressure,  pp.  142,  149. 
Cf.  also  Hirschfelder,  Diseases  of  the  Heart  and 
Aorta,  p.  46  ;  Lewandowsky,  Handbuch  der  Neuro- 
logic, III.  (ii.),  p.  40. 

2Janeway,  I.e.,  p.  160. 


IRervoug  System  31 

of  hydrocephalus  may  be  due  to  an  important  self- 
aggravating  process  (JMatC  II.  f).  The  disorder  may 
originate  in  some  obstruction  to  the  foramen  of 
Majendie  or  to  one  of  the  communicating  channels, 
causing  fluid  to  accumulate  in  the  ventricles.  The 
dilated  ventricles  may  so  displace  the  adjacent  parts 
as  to  increase  the  obstruction  to  which  the  accumul- 
ation was  primarily  due.  For  example,  the  cere- 
bellum and  medulla  may  be  pressed  into  the  foramen 
magnum  so  as  to  plug  that  aperture.  Such  plugging 
in  turn  increases  the  distention  of  the  ventricles  and 
renders  the  condition  a  self -perpetuating  one.  In 
other  cases  the  dilated  ventricles  (by  compressing 
the  membranes  of  the  nerve  roots)  may  close  both 
lymphatics  and  veins,  which  closure  in  its  turn 
leads  to  a  greater  accumulation  of  fluid.1 

A  similar  process  is  observed  in  cerebro-spinal  and 
other  forms  of  meningitis.  The  foramen  magnum 
is  sometimes  plugged  by  the  displaced  cerebellum  as 
if  by  a  cork.2 

(Edema  of  the  Brain.  Various  writers  have 
called  attention  to  the  self-perpetuating  processes  in 
oedema  of  the  brain. 

Treves  writes  : 

"  Owing  to  the  peculiar  anatomical  condition  of  the 
brain,  situated  as  it  is  in  an  almost  inexpansible  cavity, 
when  an  oedema  has  once  commenced,  a  circulus 
vitiosus  is  established,  leading  to  a  progressive  increase 
in  the  oedema."3 

Leonard  Hill  also  writes  : 

"  The  high  blood  pressure  which  exists  in  those 
capillary  areas  surrounding  the  seat  of  complete  vascular 
obliteration  will  lead  to  increased  transudation  of 
fluid,  since  plasma  may  pass  more  easily  into  the  brain 

1  British  Med.  /.,  1911,  I.,  p.  808. 

2  Carnegie  Dickson,  British  Med.  /.,  1917,  I.,  p.  454. 
3 System  of  Surgery,  II.,  p.  119. 


32  lDiciou0  Circles  in  IDieease 

substance  than  the  blood  through  the  compressed 
capillaries.  The  transudation  will  take  place  at  almost 
arterial  tension,  will  increase  the  volume  of  the  foreign 
body,  and  so  will  lead  to  compression  of  other  capillary 
areas.  A  circulus  vitiosus  is  thus  established  and  the 
cerebral  anaemia  may  spread  indefinitely." 

And  again  : 

"  In  meningitis,  tubercular  meningitis  and  cerebral 
abscess,  compression  can  arise  by  the  accumulation  of 
inflammatory  exudations,  by  inflammatory  dilatation, 
by  thrombosis  and  blocking  of  vascular  areas  ;  and 
whenever  the  Sylvian  aqueduct  and  the  veins  of  Galen 
are  obliterated  by  intraventricular  transudation.  In 
all  these  pathological  states  a  circulus  vitiosus  can  be 
established  leading  to  advancing  cerebral  anaemia. 
The  pathological  cause  of  ventricular  hydrocephalus  is 
no  doubt  to  be  found  in  blocking  of  the  veins  of  Galen 
and  the  Sylvian  aqueduct."1 

Cerebral  Congestion.  In  cases  of  locomotor 
ataxy  and  general  paralysis  the  venous  congestion 
and  increased  psychical  activity  of  the  neurons 
frequently  react  on  each  other,  the  correlations  being 
probably  due  to  the  mechanical  conditions  favouring 
stasis  in  the  frontal  and  central  convolutions,  and 
being  especially  common  where  syphilis  has  lowered 
the  "  durability  "  of  the  nervous  "system. 
Mott  writes  : 

"Psychical  activity  will  cause  hyperaemia  and 
congestion  of  the  brain,  and  in  regions  where  there  is  a 
tendency  to  stasis  the  congestion  may  persist,  especially 
if  it  leads  to  insomnia.  A  Vicious  Circle  becomes 
established  by  conditions  which  tend,  on  the  one  hand, 
to  perpetual  venous  congestion  in  certain  regions,  and' 
on  the  other  hand,  to  increased  excitability  of  the 
neurons  ;  these  factors  mutually  interact."2 

Physiology    and    Pathology    of   the    Cerebral  Circulation 

pp.  188,  197,  200. 
*  Lancet,  1900,  II.,  pp.  81,  3  ;    1913,  n     1470. 


IRervoue  £\>0tem  33 

Other  injurious  circular  reactions  may  be  estab- 
lished in  various  conditions  in  which  there  is  a  rapid 
destruction  of  neurons. 

These  Mott  has  also  described  : 

"  Two  conditions  may  mutually  interact  upon  one 
another  in  the  establishment  of  a  Vicious  Circle,  viz. 
degenerating  nervous  structures,  the  degenerated  pro- 
ducts of  which  accumulate  and  irritate  the  peri- 
vascular  lymphatics  surrounding  the  veins,  causing  a 
tendency  to  stasis  and  inflammation,  combined  with 
conditions  which  produce  mechanical  congestion  in 
the  veins  ;  and  this  reacting  back  on  the  nerve  struc- 
tures leads  to  still  further  disintegration  of  nervous 
tissue  :  and  thus  the  one  vicious  condition  feeds  the 
other."1 

Poliomyelitis.  In  anterior  poliomyelitis  arid 
other  forms  of  paralysis  morbid  correlations  may 
result  from  a  disuse  of  the  associated  muscles. 
There  is  in  fact  "  a  circle  of  reflex  and  trophic 
influences  "  affecting  the  whole  apparatus  of  nerve 
cell  and  muscle,  and  reacting  on  one  another  through 
interference  with  the  regular  exchange  of  stimuli. 

The  progress  of  events  is  well  illustrated  in  acute 
anterior  poliomyelitis  when  indeed  two  distinct 
complications  may  occur,  one  earlier  in  the  course 
of  the  disease  than  the  other. 

The  first  complication  results  from  a  disturbance 
of  the  reciprocal  relations  that  exist  between  the 
tropho-motor  neurons  and  their  associated  muscle- 
cells.  In  favourable  cases  the  inflammation  of  the 
neurons  of  the  anterior  cornua  rapidly  subsides  and 
the  neurons  recover  more  or  less  completely,  the 
percentage  of  recoveries  being  estimated  at  about 
15  per  cent.  Recovery,  however,  depends  not 
merely  on  the  central  lesion,  but  also  on  the  main- 


1  Archives  of  Neurology,  I.,  pp.  42,  179,  188,  189,  191,  501-2. 
Cf.  also  British  Med.  /.,  1911,  II.,  p.  1415. 


34  Dicious  Circles  in  Disease 

tenance  of  nutrition  and  contractility  of  the  depend- 
ent muscles.  If  these  muscles  remain  untreated 
and  disused  and  atrophy,  they  react  injuriously  on 
the  damaged  neurons  which  lose  the  stimuli  which 
should  reach  them  from  the  periphery,  and  thus 
perpetuate  the  disease. 

Robert  Jones  describes  the  process  : 

"  The  muscle  has  wasted  from  disuse  and  become 
incapable  of  responding  to  such  feeble  impulses  as  come 
to  it  from  an  impaired  nerve  cell.  Consequently  the 
normal  afferent  impulses  do  not  pass  up  to  the  nerve 
cell,  because  the  muscular  action  which  originates 
them  is  absent,  and  the  whole  reflex  apparatus  by 
which  the  spinal  nerve  cell  and  muscle  react  on  each 

other  to  their  mutual  benefit  is  put  out  of  gear 

Recovery  of  muscular  action  does  not  take  place 
spontaneously  because  the  whole  apparatus — nerve  cell, 
nerve  trunk  and  muscle — are  in  a  state  of  disuse 
atrophy,  and  continue  to  remain  so,  because  the  muscle, 
from  its  mechanical  disadvantage,  cannot  perform  its 
function  of  contracting,  which  is  an  essential  part  in  the 
circle  of  reflex  and  trophic  influences."1 

In  severe  cases  a  second  complication  occurs. 
Owing  to  the  pull  of  healthy  antagonistic  muscles, 
the  weakened  muscles  associated  with  the  central 
lesion  are  over-stretched,  and  the  result  is  a  lessened 
contractility,  increased  weakness  and  deformity. 
Over-stretching  leads  to  weakness  and  weakness 
conduces  to  over-stretching.  The  muscles  are  thus 
rendered  less  and  less  able  to  supply  the  stimuli 
necessary  for  the  nutrition  and  recovery  of  the 
central  neurons.2 


1  British  Med.  /.,   1914,  I.,  p.    u66.     Cf.   also  Hutchison 

and  Sherren,  Index  of  Treatment,  p.  5ir. 

2  A  good  account  of  the  similar  "  Vicious  reflex  Circle  "   in 

spastic     paralysis   is  given  by    Tubby    and   Jones, 
Modern  Methods  in  the  Surgery  of  Paralyses,  p.  215' 


Chapter  Jfour 


THE    CARDIOVASCULAR    SYSTEM 

I  WING  to  the  importance  of  the  cardio- 
vascular system  in  the  economy,  and 
to  the  complexity  of  the  vital  and 
mechanical  phenomena  involved,  the  cir- 
cular reactions  created  by  disease  are 
of  the  highest  interest.  These  reactions  are  difficult 
to  classify  on  any  scientific  principle,  since  the 
various  parts  of  the  cardio-vascular  system  are  so 
closely  dependent  on  one  another.  Nevertheless  an 
attempt  at  classification  must  be  made,  although 
overlapping  is  inevitable. 

We  shall  discuss  in  order  : 

I.  The  Myocardium 

II.  The  Endocardium 

III.  The  Pericardium 

IV.  Cardiac  Neuroses 

V.  The  Blood- Vessels  and  l/ymphatics 

VI.  The  Blood 

I.     THE  MYOCARDIUM 

Failure  of  Compensation.  The  compensatory 
changes  in  the  myocardium,  which  result  from 
increased  resistance  in  the  pulmonary  and  sys- 
temic circuits,  constitute  a  striking  example  of  the 
remedial  adaptations  of  nature.  In  the  course  of 
time,  however,  these  compensatory  changes  usually 
fail  and  end  in  cardiac  dilatation  and  stasis.  Hence 

35 


36  iDicious  £ircle0  in  SHsease 


results  interference  with  circulation,  respiration, 
digestion,  absorption  and  elimination.  The  unfor- 
tunate myocardium  already  labouring  under  special 
difficulties  a  fronte  is  poisoned  by  the  products  of 
imperfect  metabolism  which  reach  it  a  tergo,  sap  its 
nutrition  and  intensify  its  weakness.1  The  vortex 
steadily  increases  by  involving  one  organ  after 
another,  like  "  a  circle  in  the  water  which  never 
ceaseth  to  enlarge  itself." 

The  important  circular  reactions  thus  established 
may  be  divided  into  short,  medium  and  long 
circuits.  The  first  is  concerned  with  the  myocardium 
and  its  coronary  vessels,  the  second  with  the  myocar- 
dium and  the  pulmonary  circulation,  and  the  third 
with  the  myocardium  and  the  peripheral  circulation. 
These  several  reactions  aggravate  the  cardiac  failure 
(JMatC6  l>»  HI.  a,  b).  All  the  viscera  may  in  turn 
be  thrown  into  disorder  and  aggravate  the  cardiac 
weakness.  Thus  we  may  have  what  Barie  terms 
"  un  foie  cardiaque,  un  poumon  cardiaque,  un  rein 
cardiaque,  une  rate  cardiaque,"  and  so  forth. 

A.  The  first  organ  to  suffer  from  the  heart 
failure  is  the  heart  itself,  since  the  coronary  circula- 
tion depends  on  systolic  activity. 

West  writes  : 

"  When  the  congestion  travels  beyond  the  right 
ventricle,  one  of  the  first  sets  of  veins  to  feel  its  effects 
is  the  coronary.  In  this  way  the  circulation  of  the 
whole  heart  is  affected,  and  its  nutrition  suffers  still 
more.  The  weakness  of  the  left  ventricle  is  thus 
further  increased,  and  therefore  the  congestion  produced 
by  it,  and  so  a  Vicious  Circle  is  established  which,  if 
not  broken,  quickly  leads  to  a  fatal  issue."2 

1M.  Bruce,  Lancet,  1911,  II.,  2ro  ;    Pembrey  and  Ritchie, 

General  Pathology,  p.  283. 
-Diseases  of  the  Organs  of  Respiration,  I.,  p.  237. 


CarbicMDascular  System 


37 


(a)  CARDIAC  FAILURE 


** 

(c)  AORTIC  REOURQITATION 


(e)  VARICOSE  VEIN 


otf 

\u«- 

(b)  CARDIAC  FAILURE 


(d)  PERICARDITIS 


(f)  AN/EMIA 


Iplatc  in.— Circles  associated  witb  the 
CarMo«*lDascular  System, 


38  IDicious  Circles  in  Disease 

Various  disorders  are  associated  with  arrhythmia. 
Such  arrhythmia,  on  the  one  hand,  may  slow  the 
circulation,  thus  tending  to  produce  cyanosis  by 
increasing  the  CO2  in  the  blood  and  diminishing 
the  tone  of  the  cardiac  muscle.  On  the  other  hand, 
the  long  pauses  increase  the  venous  pressure,  while 
the  influx  of  venous  blood  under  a  relatively  increased 
pressure,  acting  on  a  cardiac  muscle  whose  tone  is 
diminished,  favours  over-distention.  The  over-dis- 
tention  by  increasing  the  diameter  of  the  ventricular 
chamber  increases  the  hydrostatic  pressure  on  its 
walls  and  causes  the  heart  to  work  at  a  disadvantage. 

Hirschf elder  thus  represents  two  of  "  the  Vicious 
Circles  of  the  irregular  heart  :  "l 

A 

Permanent  arrhythmia 

t  1 

Weak  and  irritable  heart  Slow  circulation 

t  1 

Impaired  nutrition  of  heart  cells 

B 

Over-filling  of  heart 

t  1 

Slowing  of  circulation    < —     Irregularity 

In  other  cases  progressive  paroxysms  of  auricular 
fibrillation  occur.  Such  paroxysms  are  due  to  the 
fact,  experimentally  observed,  that,  as  Lea  points 
out,  "auricular  fibrillation  itself  tends  to  increase 
the  irritability  of  the  auricle  and  so  sets  up  a  Vicious 
Circle."2 

Diseases  of  the  Heart  and  Aorta,  pp.  123,  127.     Cf.  also 

/.  of  American  Med.  Ass.,  1908,  II.,  p.  476. 
2 Lancet,  1912,  II.,  p.  I2r6. 


CarbiotDascular  £pstem  39 

Other  reciprocally  acting  processes  result  from  de- 
generative changes  of  the  myocardium,  and  the 
associated  dilatation  of  the  cardiac  chambers.  Since 
the  strain  on  the  walls  of  a  sphere  or  spheroid  in- 
creases with  its  circumference,  the  weakened  and 
dilated  cardiac  walls  yield  the  more  under  the  strain 
of  the  systolic  pressure  ;  the  more  they  yield  the 
greater  the  strain  and  vice  versa.  Dilatation  begets 
dilatation.  Even  the  fall  of  velocity  under  such 
conditions  perpetuates  itself.1 

In  cases  of  advanced  myocardiac  degeneration 
actual  rupture  of  the  heart  may  occur,  followed  by 
haemorrhage  and  rapid  fall  of  blood-pressure.  This 
fall  in  its  turn  stimulates  the  vaso-motor  centre  in 
the  bulb  and  provokes  a  general  vaso-constriction, 
which  again  raises  the  blood-pressure  and  intensifies 
the  haemorrhage,  thus  hastening  death. 

Another  injurious  process  may  be  associated  with 
the  Adam-Stokes  syndrome,  i.e.  the  co-existence  of 
extreme  bradycardia  and  syncopal  or  convulsive 
seizures. 

Lewandowsky  writes  : 

"  In  cases  of  partial  heart-block  the  condition  may 
pass  into  one  of  complete  heart-block,  possibly  owing 
to  an  increased  frequency  of  the  auricular  contraction 
due  to  psychical  excitement  or  to  exertion.  In  such 
cases  the  stimuli  may  be  insufficient,  as  the  experi- 
ments of  Erlanger  have  shewn  (relatively  complete 
heart-block).  The  resulting  interference  with  the 
circulation  through  the  brain  or  the  medulla  then 
brings  on  the  attack. 

An  extra-cardiac  origin  is  also  conceivable  in  cases 
where  the  bulbar  activity  is  impaired  owing  to  vaso- 
constriction  or  to  a  temporarily  defective  vascular 
supply — i.e.  where  there  is  intermittent  loss  of  functional 
activity  of  the  medulla.  Such  a  condition  might  in  its 

'Allbutt,  Diseases  of  the  Arteries,  II.,  p.  58. 


40  IDidous  Circles  in  Diseaee 

turn  act  on  the  heart,   and  by  means  of  a  Vicious 
Circle  react  again  through  the  heart  on  the  brain."1 

Failure  of  compensation  is  sometimes  complicated 
by  extreme  tachycardia,  the  pulse-rate  reaching 
250  or  even  300  per  minute,  and  the  blood-pressure 
falling  to  as  low  as  50  mm.  Hg.  Such  a  low  pressure 
indeed  is  a  serious  danger  in  itself  and  may  lead  to 
sudden  death.  Moreover  the  interval  between  the 
cardiac  beats  is  so  short  that  the  ventricles  can 
neither  fill  nor  empty  themselves  as  they  should. 
These  conditions  perpetuate  the  tachycardia  and 
low  pressure. 

Huchard  writes  : 

"  A  Vicious  Circle  is  created  from  which  the  sufferer 
cannot  escape  until  his  depressed  arterial  blood- 
pressure  has  been  raised."2 

B.  After  the  myocardium  itself  the  lungs  bear 
the  brunt  of  cardiac  failure,  the  diminished  propulsive 
and  suction  forces  being  perhaps  equally  injurious. 
Stasis  in  the  lungs  spells  impaired  aeration,  and 
impaired  aeration  spells  increased  myocardial  weak- 
ness. Thus  there  is  reciprocal  embarrassment  in 
two  of  the  most  vital  parts  of  the  organism.3  A 
similar  embarrassment  is  met  with  in  many  diseases 
associated  with  cardiac  failure,  e.g.  bronchitis, 
pneumonia,  acute  pulmonary  oedema,  hypostatic 
pulmonary  congestion  etc. 

Cardiac  failure  is  frequently  complicated  by 
paroxysms  of  dyspnoea  which  tend  to  aggravate  the 
condition.  The  attacks  usually  occur  during  sleep 

^andbuch  der  Neurologic,  V.  (iv.),  p.  12. 

2 Maladies  du  Cceur  et  de  1'Aorte,  I.,  pp.  16,  100.     Cf.  also 

Pavlov,  The  Work  of  the  Digestive  Glands,  p  233  ; 

American  J.  of  Surgery,  1914,  II.,  p.  n. 
3Fothergill  gives  an  excellent  account  of   the  pathological 

sequences  in  which  the  heart  and  lungs  are  involved. 

Lancet,  1874,  II.,  p.  682. 


System  41 


or  in  the  early  morning  when  the  blood-pressure  is 
low,  and  give  rise  to  extreme  dyspnoea,  tumultuous 
palpitation,  acute  distress,  insomnia  and  prostration. 
Various  pathological  conditions  may  excite  such 
an  attack  ;  but  broadly  speaking  they  spring  from 
cardiac  inadequacy  while  in  their  turn  they  increase 
the  inadequacy  and  may  terminate  fatally.  The 
cardiac  and  respiratory  rhythm  are  thrown  into 
confusion  and  the  want  of  harmonious  action  throws 
an  extra  strain  on  each  of  them. 

C.  The  third  group  includes  the  peripheral 
circulation,  and  especially  the  portal  system.1 

Barie  thus  describes  "  le  foie  cardiaque  "  : 

"  The  liver,  whose  functions  are  thrown  out  of  gear 
as  a  result  of  cardiac  failure,  in  its  turn  reacts  on  the 
heart  and  aggravates  the  venous  stasis  on  the  right 
side  of  the  heart.  Thus  it  comes  about  that  heart 
failure  associated  with  hepatic  diseases  (asystolie 
hepatique)  gives  rise  to  a  veritable  Vicious  Circle, 
due  to  the  heart  and  the  liver  alternately  reacting  on 
one  another."2 

Some  cases  of  cardiac  failure  are  complicated  by 
flatulent  distention  of  the  stomach  due  to  the 
consequential  congestion  of  the  stomach.  Such 

1  Every  circulus  vitiosus  has  of  course  its  corresponding 
circulus  virtuosus.  For  example,  the  three  circuits  — 
short,  medium  and  long  —  would  form  the  following 
physiological  sequences  in  the  healthy  individual  :  — 

A.  Vigorous  systole  :  active  coronary  circulation  : 
good  nutrition  of  myocardium  :  vigorous  systole. 

B.  Vigorous   systole  :    active    pulmonary   circu- 
lation :   efficient  oxygenation  :  vigorous  systole. 

C.  Vigorous  systole  :  active  visceral  circulation  : 
good  digestion  and  nutrition  :  vigorous  systole. 

2Maladies  du  Cceur  et  de  1'Aorte,  pp.  632,  771. 


42  IDickws  Circles  in  Bieeaee 

cardiac  embarrassment  can  actually  turn  the  scale 
against  recovery  when  life  is  trembling  in  the  balance. 
Halls  Dally  who  illustrates  this  condition  diagram- 
matically  gives  the  following  as  the  ten  component 
factors  of  this  "  cardio-gastric  Vicious  Circle"  : 
failure  of  compensation  :  portal  congestion  :  catarrh 
of  stomach  :  delayed  or  imperfect  digestion  :  fer- 
mentation and  flatulence  :  raising  of  diaphragm  : 
displacement  of  heart  :  kinking  of  great  vessels  : 
raised  venous  and  lowered  arterial  pressure  :  cardiac 
over-strain  and  so  back  to  failure  of  compensation.1 
These  visceral  complications  might  be  extended 
so  as  to  include  the  spleen,  the  intestines,  the  kidneys 
and  so  forth.  Indeed  the  entire  peripheral  circula- 
tion is  involved.  But  as  the  same  principle  is  at 
work  further  details  are  unnecessary  ;  they  all  go 
to  show  how  often  the  heart,  in  the  words  of  Allbutt, 
"  falls  into  the  Vicious  Circle  of  doing  as  ill  for  itself 
as  for  other  parts  of  the  body."2 

Cardiac  Strain.  Some  striking  circular  reactions 
are  met  with  in  cases  of  acute  dilatation  due  to  over- 
exertion.  For  example,  the  dilatation  may  cause 
such  weakening  of  the  coronary  circulation  that  the 
myocardium  loses  much  of  its  contractile  power. 
The  result  is  a  further  diminution  of  the  coronary 
supply,  followed  by  still  further  weakening  of  the 
cardiac  muscle.  This  sequence  results  from  the  fact 
that  the  cardiac  muscle  is  fed  by  the  blood  which 
it  circulates  and  is  thus  self-dependent. 

The  dramatic  death  of  Eucles  after  the  victory  at 
Marathon  was  probably  due  to  acute  dilatation. 
After  racing  to  Athens  with  the  good  news  he  was 


1  Progressive  Medicine  (1913),  III.,  p.  100.     Cf.  also  Stacey 

Wilson,  The  Early  Diagnosis  of  Heart  Failure,  p.  368. 

2  Allbutt  and  Rolleston,  System  of  Medicine,  III.,  p.  388. 


CarbicMDascular  System  43 

just    able    to    shout   the    words     XaV€T€>  Xat/)0/xei', 
before  he  fell  dead.1 

Cardiac  dilatation,  according  to  Ehrnrooth,  is 
largely  due  to  diminished  contact  between  the  muscle 
cells  since  such  lessened  contact  (in  the  absence  of 
nerve  fibres)  diminishes  conductivity.  Stasis  also 
supervenes  before  long,  followed  by  exudation  which 
further  diminishes  contact. 

Ehrnrooth  writes  : 

"  In  this  way  a  Vicious  Circle  is  established  which 
affects  the  primary  functions  of  the  muscular  tissues."2 

In  other  cases  an  over-strained  and  weakened 
heart  is  associated  with  an  abnormally  high  pressure. 
The  slowing  of  the  circulation  due  to  the  strain 
tends  to  produce  anaemia  of  the  medullary  centres, 
which  respond  by  inducing  intense  vaso-constriction, 
thereby  driving  a  larger  quantity  of  blood  to  the 
medullary  centres.  The  already  weakened  heart  is 
called  upon  to  make  a  supreme  effort,  and  the 
weaker  it  is  the  more  do  the  imperious  medullary 
centres  call  for  blood.  The  cardiac  weakness  and 
the  bulbar  anaemia  aggravate  each  other,  and  the 
increased  arterial  pressure  may  be  kept  up  to  the 
end  in  persons  dying  of  heart  failure  induced  by  that 
high  pressure.  The  forced  draught  under  which 
the  hydro-dynamic  system  is  working  leads  to  its 
destruction.3 

Somewhat  similar  conditions  may  result  from 
acute,  more  especially  zymotic,  disease,  such  as 
pneumonia,  influenza,  diphtheria  and  enteric  fever. 
Indeed  any  disease  that  gravely  diminishes  the 

1  Plutarch,  Opera  Moralia,  ed.  by  Didot,  I.,  p.  425.  Cf.  also 
Barie,  Maladies  du  Coeur  et  de  1'Aorte,  pp.  612,  631. 

2Uber  Plotzlichen  Tod  durch  Herzlahmung,  p.  24. 

3  A  high  venous  pressure  may  also  create  a  dangerous 
circular  reaction.  Norris,  Blood-Pressure,  p.  20. 


44  IDictoue  Circles  in  Disease 

cardio-motive  forces  may  bring  this  morbid  correla- 
tion into  play.  Weak  systole  :  inadequate  circula- 
tion :  weaker  systole — represents  a  dangerous 
sequence.  In  serious  attacks  "  there  is  a  Vicious 
Circle  of  conditions  which  precludes  all  hope  of 
recovery."1  Especially  is  this  result  probable  when 
the  blood  supplied  to  the  myocardium  is  laden 
with  impurities,  or  when  there  is  a  progressive 
accumulation  of  residual  blood  leading  to  increasing 
dilatation  of  the  ventricle.  Then  indeed  does  life 
hang  by  a  thread  which  may  snap  at  any  moment. 

Coronary  Sclerosis.  Malnutrition  of  the  myocar- 
dium is  not  infrequently  due  to  sclerosis  of  the 
coronary  arteries,  a  condition  which  accounts  for 
the  sudden  death  of  many  elderly  persons.  After 
gradually  advancing  for  years,  the  sclerosis  may 
reach  a  stage  when  the  lumen  of  the  coronary 
arteries  is  almost  blocked  by  degenerative  changes 
so  that  the  blood-supply  to  the  myocardium  is 
seriously  curtailed.  The  increased  resistance  pro- 
duced by  the  sclerosis  requires  a  more  forcible 
systole,  if  life  is  to  continue,  whereas  the  systole  is 
actually  weakened  owing  to  the  diminished  blood- 
supply,  and  the  weakening  further  impairs  the 
coronary  circulation.  At  last  the  heart  gives  up 
beating. 

"  The  insufficiency  is  due  to  the  Vicious  Cycle 
created  by  lowering  the  pressure  in  the  coronary 
arteries,  which  occurs  directly  the  ventricle  is  unable 
to  maintain  the  required  aortic  pressure.  Thus  at  the 
very  time  when  the  heart  muscle  requires  the  greatest 
supply  of  nutrition,  the  supply  of  blood  to  the  myocar- 
dium lessens."2 

1  Osier  and  Macrae,  System  of  Medicine,  IV.,  p.  125.    Cf. 

also  Cohnheim,  General  Pathology,  III.,  p.  1416. 

2  Osier  and  Macrae,  System  of  Medicine,  IV.,  p.  31.     Cf. 

also  M.  Bruce,  Lancet,  1911,  II.,  pp.  70,  206  ;    Mac- 
Callum,  Text-Book  of  Pathology,  p.  467. 


CarMcMDascular  System  45 

Angina  pectoris  is  often  associated  with  this 
pernicious  sequence  of  events,  the  pain  being 
probably  due  to  spasm  or  cramp  of  the  cardiac 
muscle  which  cannot  obtain  an  adequate  supply  of 
blood. 

II.     THE    ENDOCARDIUM 

The  compensatory  changes  which  take  place  when 
the  myocardium  has  to  meet  increased  resistance 
have  been  alluded  to  in  the  previous  section.1  Such 
increased  resistance  is  frequently  caused  by  valvular 
disease,  and  mutatis  mutandis  similar  compensatory 
changes  result.  Here  also  in  course  of  time  decom- 
pensation follows,  and  gives  rise  to  the  secondary 
conditions  described  in  connection  with  the  failure 
of  the  myocardium. 

Gibson  writes  : 

"  Sooner  or  later,  according  to  its  form  and  severity 
chronic  valvular  disease  with  compensation  itself 
disposes  to  failure  by  establishing  a  "Vicious  Circle  of 
slow  progressive  impairment  of  the  viscera  and  their 
great  vital  functions — the  lungs,  liver,  stomach,  bowels, 
kidneys,  indeed  the  myocardium  itself."2 

The  several  valvular  lesions,  however,  may  estab- 
lish special  correlations  which  are  peculiar  to  them- 
selves, and  these  are  worthy  of  a  brief  consideration, 
for,  as  Bouillaud  says  :  "  The  various  diseases  of 
the  heart  may  themselves  cause  other  diseases  in 
that  organ."3 

1  Pembrey  and  Ritchie  point  out  that  when  a  hypertrophied 
heart  exceeds  a  certain  size  its  work  is  increased  by 
the  restrictions  of  the  bony  thorax.  Thus  hyper- 
trophy may  mean  more  work  and  still  greater 
hypertrophy.  General  Pathology,  p.  287. 

-Text-Book  of  Medicine,  II.,  p.  127.  Cf.  also  H.  Sainsbury, 
Lancet,  1917,  II.,  p.  871. 

^Huchard,  Maladies  du  Cceur  et  de  1'Aorte,  III.,  p.  717. 


46  iDicioue  Circles  in  Biseaec 

Aortic  Regurgitation.  Regurgitation  due  to 
disease  of  the  aortic  valves  is,  under  favourable 
circumstances,  compensated  by  hypertrophy  of  the 
left  ventricle,  which  supplies  the  increased  driving 
power  necessitated  by  the  lesion  (jpIatC  III.  c).  For 
many  years  the  individual  affected  may  lead  a  use- 
ful comfortable  life,  and  be  scarcely  conscious  of 
anything  amiss.  Sooner  or  later,  however,  the 
hypertrophied  ventricle  undergoes  an  injurious  de- 
gree of  dilatation.  The  myocardium  is  insufficiently 
irrigated  and  nourished,  and  the  condition  may 
lead  to  sudden  death.  The  following  is  the  fatal 
sequence  :  regurgitation,  impaired  coronary  circu- 
lation, dilatation,  weakened  systole  and  increased 
regurgitation. 

Incompetence  of  the  aortic  valve  may  also  result 
from  disease  and  dilatation  of  the  aorta,  especially 
in  middle  and  old  age.  This  is  in  turn  followed  by 
dilatation  and  lessened  competence. 

McKisack  writes  : 

"  The  ventricle  under  these  circumstances  usually 
becomes  dilated,  partly  as  a  result  of  fatty  and  fibrous 
degeneration,  and  partly  as  the  effect  of  mechanical 
causes  set  up  by  the  defective  aortic  valve,  so  that  a 
Vicious  Circle  is  established."1 

Occasionally  an  aortic  valve  may  rupture  under 
severe  exertion,  thus  throwing  a  sudden  strain  on 
the  heart  for  which  it  is  unprepared.  The  same 
injurious  sequence  takes  place,  but  as  there  has  been 
no  time  for  compensatory  change  the  effects  are 
more  serious  and  instantaneous  death  may  occur. 

Broken  compensation  associated  with  aortic 
insufficiency  may  also  be  complicated  by  a  high 
diastolic  pressure  which  aggravates  the  insufficiency. 


1  British  Med.  /.,  1911,  II.,  p.  1397. 


(TarbtcMDaecular  Spetem  47 

Hirschf elder  thus  represents  the  correlations  :l 
Cardiac  weakening 


i 


Increased  cardiac   effort  Slowed  circulation 

High  blood-pressure  through  medulla 

Vaso-constriction 

Mitral  Stenosis.  Mitral  stenosis  is  one  of  the 
commonest  causes  of  heart  failure.  The  nutrition  of 
the  auricular  musculature  suffers  greatly  and  this 
hampers  the  flow  of  blood  through  the  stenosed 
orifice. 

Coombs  writes  : 

"  In  a  large  majority  of  all  cases  of  mitral  stenosis 
death  is  due  to  gradual  cardiac  failure.  The  powers 
responsible  for  this  are  two.  The  heart  and  especially 
the  left  auricle  are  asked  to  do  more  work  by  reason 
of  the  valvular  obstruction  ;•  and  further  the  gradually 
increasing  venous  stasis  undermines  the  nutrition  of 
the  cardiac,  and  particularly  of  the  auricular  muscul- 
ature. An  unconquerable  Vicious  Circle  is  now  estab- 
lished."2 

Mitral  Regurgitation.  When  mitral  regurgitation 
is  consequent  on  aortic  regurgitation  or  obstruction 
(owing  to  progressive  dilatation  of  the  ventricle  and 
auriculo-  ventricular  orifice)  there  may  be  a  reciprocal 
influence  on  each  other  of  the  aortic  lesion  and 
the  mitral  regurgitation.  The  cumulative  result  is 
usually  disastrous. 


jDf  the  Heart  and  Aorta,  p.  315. 
2Rendle  Short,  Index  of  Prognosis,  p.  221. 


48  IDicious  Circles  in  Disease 


Another  sequence  may  be  associated  with  mitral 
regurgitation  when  the  cusps  of  the  valve  are  not 
brought  tightly  together,  owing  to  want  of  cardiac 
tone/  A  small  leak  may  thus  be  transformed  into 
a  serious  one,  leading  to  a  further  diminution  of 
tonicity. 

Hirschfelder  thus  represents  the  condition  : 1 
Leak  at  mitral  valve 

1  f 

Papillary  or  Heart  strain 

relative  insufficiency  "  Diminished  tonicity 

Tricuspid  Regurgitation.  Tricuspid  regurgita- 
tion sometimes  results  from  the  dilatation  of  the 
right  ventricle,  secondary  to  mitral  disease.  For  a 
time  the  reflux  may  relieve  the  overloaded  ventricle, 
but  its  ultimate  effect  is  to  render  the  ventricle  less 
competent  to  overcome  the  obstruction,  thus  tending 
to  increased  dilatation. 

Septic  Endocarditis.  In  the  case  of  septic  endo- 
carditis an  infective  Circle  may  be  established  by 
the  micro-organisms  circulating  in  the  blood.  These 
microbes  lead  to  vegetations  and  erosions  in  the 
endocardium,  especially  that  lining  the  valves,  and 
these  vegetations  throw  off  showers  of  infective 
emboli  carrying  infection  far  and  wide  and  leading 
to  further  endocardial  lesions.  For  example,  the 
vegetations  due  to  rheumatic  fever  are  highly 
susceptible  to  attack  by  the  streptococcus,  pneu- 
mococcus,  gonococcus  or  similar  organisms. 


Diseases  of  the  Heart  and  Aorta,  p.  414.     Cf.  also  Allbutt, 
Diseases  of  the  Arteries,  I.,  p.  129. 


CarfciolDascular  System  49 

Valvular  disease  usually  leaves  a  legacy  oi  mischief 
behind.  The  patient  does  not  die  but  remains  an 
invalid,  the  sanatio  incompleta  being  shown  by  a 
disposition  to  relapse,  by  a  diminished  power  of 
resistance  to  fresh  attack.  As  a  taper  just  blown 
out  will  snatch  the  flame  from  the  torch  that  scarcely 
touches  it,  even  so  readily  is  the  endocardiac  mis- 
chief rekindled.  Thus  the  valvular  mischief  and  the 
lowered  resistance  act  and  react  on  each  other,  often 
ending  in  extensive  and  cumulative  mischief. 

When  valvular  lesions  occur  in  such  persons  as 
navvies  or  coalheavers,  whose  daily  occupation  in- 
volves severe  exertion,  disastrous  consequences  usu- 
ally follow  much  earlier  than  they  would  do  were 
the  regime  of  life  more  favourable  to  compensation. 
Many  a  premature  death  has  occurred  where  poverty 
or  adverse  fortune  has  compelled  a  life  of  toil.  The 
labour  aggravates  the  heart  lesion  ;  the  heart  lesion 
makes  the  daily  task  relatively,  if  not  absolutely, 
harder. 

Congenital  Heart  Disease.  Congenital  heart 
disease  is  usually  due  to  imperfection  either  of  the 
valves  or  of  the  septa  caused  by  fcetal  endocarditis. 
The  malformation  frequently  interferes  with  the 
nutrition  of  the  myocardium,  thus  diminishing  its 
blood-supply  and  further  impairing  systolic  activity. 
For  example,  a  patent  foramen  ovale  when  associated 
with  pulmonary  stenosis  often  gives  rise  to  reciprocal 
disorders.  So  long  as  a  quiet  mode  of  life  is  pursued, 
sufficient  blood  passes  through  the  lungs  to  keep  the 
blood  aerated,  while  the  remaining  blood  passes 
through  the  foramen  ovale  which  offers  less  resis- 
tance. But  as  soon  as  active  exercise  is  taken,  a 
larger  quantity  of  blood  passes  direct  into  the  left 
auricle  and  ventricle  (owing  to  the  pulmonary 
stenosis)  and  thus  escapes  oxygenation .  The  con- 
sequence is  a  rise  in  venous  pressure  which  drives 
still  more  blood  through  the  foramen  ovale. 


5o  IDictoug  Circles  in  2>igease  _ 

Hirschf  elder  thus  represents  "  the  Vicious  Circle 
of  the  open  foramen  ovale."1 

Increased  work  of  Heart 

i        i 

Cyanosis,  Asphyxia  High  pressure  in  Vena 

Cava 


Passage  of  unaerated 
Blood  into  left  Auricle 

In  other  forms  of  congenital  morbus  cordis  the 
venous  stasis  may  give  rise  to  prolonged  convulsions. 
These  in  their  turn  interfere  with  respiratory  move- 
ments, aggravate  the  venosity  and  involve  a  grave 
menace  to  life. 

A  third  condition  may  occur  in  cases  of  congenital 
malformation  associated  with  cyanosis.  The  general 
venous  stagnation  causes  dilatation  and  tortuosity 
of  the  capillaries  in  the  skin  as  well  as  in  the  internal 
organs  and  such  dilatation  increases  the  stasis.2 

III.    THE   PERICARDIUM 

The  pericardium  is  a  comparatively  simple  struc- 
ture when  compared  with  the  heart  which  it  envelops, 
and  is  not  so  frequently  affected  by  injurious  circular 
reactions.  Nevertheless,  as  in  the  case  of  other 
serous  membranes,  there  are  certain  reciprocations  to 
which  attention  may  be  drawn. 

Slight  attacks  of  pericarditis  may  be  followed  by 
complete  recovery  even  when  there  has  been  some 
fibrinous  exudation.  After  a  series  of  attacks, 

Diseases  of  the  Heart  and  Aorta,  pp.  528,  539. 

2  Osier  and  Macrae,  System  of  Medicine,  IV.,  p.  335.     Cf. 

also  St.  Thomas'  Hospital  Reports   (1888),  XVIII., 

p.  285. 


CarbiolDaecular  System  51 

however,  the  restitutio  ad  integrum  is  generally 
imperfect.  The  acute  attack  subsides,  but  leaves 
behind  a  liability  to  recrudescence  ;  the  damaged 
pericardium  on  slight  exposure  to  chill  or  infection 
is  attacked  afresh,  and  each  time  the  damage 
increases,  until  the  cumulative  effects  may  be 
prodigious.  The  residual  lesion  predisposes  to  re- 
currence ;  recurrence  aggravates  the  primary  residual 
lesion. 

Pericardial  Effusion.  Pericardial  effusions  may 
be  self-aggravating  through  interference  with  the 
mechanism  known  as  the  lymphatic  pump,  by 
means  of  which  a  constant  circulation  of  fluid  into, 
and  out  of,  the  pericardial  cavity  is  maintained. 
This  pump  is  worked  by  means  of  the  cardiac  and 
respiratory  movements  acting  on  the  lymphatics 
and  stomata  ;  owing  to  this  mechanism  the  peri- 
cardial sac  as  a  rule  contains  no  free  fluid. 

In  cases  of  effusion  the  stomata  are  readily  blocked 
by  fibrinous  deposits,  which  check  the  escape,  and 
thus  lead  to  an  increase,  of  the  effusion.  The 
stomata  and  superficial  lymphatics  are  also  liable 
to  be  compressed,  the  channels  of  absorption  being 
thus  choked  (JMatC  III.  d). 

Again  the  effusion  impairs  the  cardiac  move- 
ments on  which  depends  the  efficiency  of  the  pump, 
and  compresses  the  great  vessels  at  the  roots  of  the 
lungs,  heart  and  pericardium.  The  circulation  is 
hampered  and  the  hampering  increases  the  effusion. 
These  reciprocally  acting  factors  may  explain  why 
pericardial  effusions  are  often  very  persistent. 

Fluid  in  the  pericardium,  whether  resulting  from 
effusion  or  from  rupture  of  an  aneurysm,  may 
involve  deadly  peril  when  it  interferes  with  the 
stretching  of  the  cardiac  walls  which  is  so  essential  to 
the  development  of  their  energy. 

Forsyth  gives  the  following  account  of  a  fatal 


52  IDicioue  Circlee  in  Disease 

sequence  due  to  this  condition  : 

"  There  can  be  no  doubt  that  the  pericardial  effusion 
was  the  cause  of  death,  and  that  its  fatal  effect  was  due 
to  mechanical  interference  with  the  circulation.  Six 
ounces  of  fluid  were  rapidly  poured  out  around  the 
heart.  The  strong  fibrous  coat  of  the  pericardium 
was  too  rigid  to  relax  for  its  accommodation,  and  a 
sac  large  enough  to  contain  only  the  heart  was  now 
occupied  by  the  heart  and  effusion.  The  result  was  a 
positive  pressure  in  the  pericardium  leading  to  com- 
pression of  the  thin-walled  vense  cavae  and  obstructed 
return  of  blood  to  the  auricles.  The  pulmonary  veins 
shared  the  fate  of  their  neighbours,  and  their  blood 
was  stemmed  back  until  the  lung  capillaries  grew  over- 
swollen.  This  led  to  oedema  of  the  lungs  and  a  copious 
exudation  into  their  alveoli  of  serum  and  even  blood, 
the  irritation  of  which  stirred  up  violent  attacks  of 
coughing.  The  coughing  raised  the  intra-thoracic 
pressure  still  higher  and  the  diastolic  filling  of  the  heart 
became  a  matter  of  difficulty.  This  again  aggravated 
the  lung  condition,  and  so  the  Vicious  Circle  went 
round — heart,  lung,  lung,  heart — with  the  pericardial 
effusion  for  its  centre."1 

Hydro-pericardium  is  a  frequent  complication  of 
heart  failure  and  results. from  general  venous  stasis, 
under  similar  conditions  as  does  drops}^  of  the  pleural 
or  peritoneal  cavities.  The  fluid,  if  abundant,  aggra- 
vates the  circulatory  embarrassment  by  interference 
with  the  cardiac,  especially  the  diastolic  movements, 
much  as  in  the  case  of  acute  pericarditis  just  referred 
to.  Such  dropsical  effusion  often  constitutes  a 
terminal  phenomenon. 

Gibson  writes  : 

"  Hydro-pericardium  may  be  said  to  step  in  as  the 
closing  link  of  a  pathological  chain,  and  once  it  has 

1  Clinical  /.,  XXVII.,  p.  220.  Cf.  also  Lancet,  1917,  I., 
p.  292  ;  Constipation  and  some  Associated  Dis- 
orders, pp.  130-1. 


(Tarfcfo-lDascular  System  53 

made  its  appearance  it  unites  with  the  other  morbid 
conditions  to  form  a  Vicious  Circle  of  fatal  import."1 

IV.     CARDIAC  NEUROSES 

Cardiac  neuroses  have  already  been  briefly  alluded 
to  in  connection  with  neurasthenia  (Cf.  p.  17). 
But  there  are  other  circular  reactions  to  which 
attention  may  be  drawn.  An  example  is  some- 
times seen  when  a  practitioner  erroneously  dia- 
gnoses a  "weak  heart"  and  excites  in  his  patient 
an  ever-present  dread  of  serious  illness  or  immediate 
death  ;  the  injurious  process  is  here  due  to  hetero- 
suggestion.  Sir  Douglas  Powell  aptly  illustrates 
this  form  of  neurosis  by  the  story  of  a  young  woman, 
once  the  picture  of  health  and  vigour,  whose  doctor 
had  diagnosed  a  "  weak  heart."  She  had  been  tak- 
ing the  utmost  care  of  a  healthy  organ  ever  since, 
resting  half  the  day,  never  even  walking  upstairs, 
until  she  became  fat,  breathless,  anaemic  and  miser- 
able. Many  months  elapsed  before  she  could  be 
weaned  back  to  her  former  healthy  activity,  if  in- 
deed recovery  were  even  then  possible.2 

A  similar  lamentable  condition  is  sometimes 
brought  about  when  excessive  repose  is  prescribed 
after  an  attack  of  angina  or  some  other  functional 
disorder.3  The  over-rested  heart  grows  more  and 
more  unequal  to  its  task,  and  more  and  more  irritable 
when  extra  demands  are  made  upon  it.  The  sufferer 
also  tends  to  grow  obese  with  a  sluggish  circulation 
which  further  impairs  cardiac  activity. 

When  a  neurotic  temperament  is  associated  with 
real  morbus  cordis,  other  injurious  correlations  may 
be  established  if  the  patient  takes  an  unduly  gloomy 


1  Diseases  of  the  Heart  and  Aorta,  p.  386.     Cf.  also  Saundby, 

Old  Age,  p.  87. 

-Treatment  in  Diseases  and  Disorders  of  the  Heart,  p.  15. 
3Hucliard,  Maladies  du  Cozur  et  de  1'Aorte,  II.,  p.  140. 


54  IDidoug  Circles  in  Bt0eage 

view  of  his  malady.  Such  pessimism  delays  com- 
pensation and  must  be  strenuously  combated. 
Frequently  the  physician  who  realises  the  value 
of  equanimity  in  promoting  compensation,  and 
how  a  knowledge  of  the  whole  truth  may  rob  a 
patient  of  all  peace  of  mind  may  hesitate  as  to 
how  much  he  should  reveal.  As  Frantzel  says  : 
"  Das  Wissen  is  oft  viel  schlimmer  als  die  Krankheit 
selbst." 

M.  Bruce  refers  to  the  condition  : 

"  Depressing  emotions  contribute  to  failure  of  com- 
pensatory hypertrophy  of  the  heart,  and  in  this  re- 
spect a  Vicious  Circle  is  formed,  which  can  often  be 
broken  by  judicious  management."1 

In  other  neurotic  patients  a  functional  disorder 
such  as  palpitation  may  start  the  morbid  train  of 
symptoms.  The  palpitation  may  be  so  violent  as  to 
cause  an  apprehension  of  sudden  dissolution,  and 
this  apprehension  in  turn  intensifies  the  palpitation. 

Arrhythmia  may  also  give  rise  to  a  severe  neurosis. 
Moreover  the  habit  of  intermitting  may  cause  an 
exaggerated  irritability  of  the  cardiac  nerve  centres, 
leading  to  a  continuance  of  the  abnormal  action 
even  after  the  removal  of  the  primary  cause. 

Some  cardiopaths  are  troubled  with  attacks  of 
vomiting  or  cough,  probably  due  to  irritation  of  the 
pneumogastric  nerves.  Such  reflex  disturbances 
aggravate  the  cardiac  trouble  or  may  even  prove 
fatal.2 

Angina  Pectoris.  Angina  pectoris  is  associated 
with  such  a  variety  of  organic  and  functional 
disorders  that  it  might  legitimately  be  classified 
under  several  headings  ;  there  may  be  myocardiac 

Principles  of  Treatment,  p.  81. 
2M.  Bruce,  I.e.,  p.  308. 


CarMo*lDa0cuIar  System  55 

failure,  valvular  lesion  or  peripheral  or  central 
spasmodic  neuroses.  One  or  more  of  these  factors 
may  be  present  and  the  allocation  of  the  precise 
share  of  each  in  the  attack  may  be  impossible. 

Morison  thus  describes  some  of  the  disorders 
which  establish  a  circular  reaction,  but  the  conditions 
vary  greatly  : 

"  vSuch  agencies  as  cold,  emotional  excitement, 
reflex  disturbances  from  various  organs,  and  certain 
poisons,  which  even  tobacco  may  prove  to  be  at  times, 
may  commence  the  Vicious  Cycle  by  inducing  the 
peripheral  spasm  which  finds  expression  in  angina. 
But  that  such  peripheral  conditions,  even  in  these 
circumstances,  require  the  presence  at  the  centres  of 
some  state  or  states  in  the  majority  of  cases,  which 
aid  the  peripheral  resistance  to  find  expression  in  pain 
is,  I  imagine,  quite  indisputable.  Given  a  weak  spot 
at  the  centre,  capable  of  registering  a  rise  of  pressure 
in  the  vascular  system,  that  rise  may  be  registered  as 
pain,  however  the  increase  of  pressure  may  be  brought 
about,  whether  by  central  propulsion  or  peripheral 
resistance.  But  that  a  patient  with  dissecting  aneurism 
of  the  coronary  artery,  with  neurotic  processes  active  in 
the  aorta  and  coronary  system,  and  with  a  delicate  and 
minute  innervation  of  every  fibre  in  the  cardiac  muscle, 
should  invariably  wait  upon  the  remote  periphery  for 
the  signal  of  distress  is  simply  unthinkable,  and  may 
even  be  regarded  as  an  opinion  no  longer  tenable."1 

V.     THE  BLOOD-VESSELS  AND  LYMPHATICS 

The  blood-vessels  have  already  been  referred  to  as 
participating  with  the  heart  in  the  creation  of 
injurious  circular  reactions.  It  will,  however,  be 
convenient  to  describe  under  a  special  heading  some 
further  disorders  in  which  they  play  a  prominent 
part. 

1  Sensory  and  Motor  Disorders  of  the  Heart,  p.  112. 


56  Widens  Circles  in  Disease 

Arterio"Sclerosis.  Important  correlations  exist 
between  arterial  sclerosis  and  cardiac  hypertrophy, 
although  pathologists  are  not  agreed  as  to  the 
precise  sequence  of  events.  At  one  time  it  was 
believed  that  the  blood  in  chronic  Bright 's  disease 
was  poisoned  by  the  products  of  metabolism,  which 
were  retained  in  the  body  instead  of  excreted  through 
the  kidneys.  To  protect  the  tissues  from  being 
damaged  by  this  vitiated  blood  the  arterial  coats 
contracted  and  hypertrophied  so  as  partially  to  cut 
off  the  supply.  Then  the  myocardium  in  its  turn 
hypertrophied  in  order  to  propel  an  adequate  supply 
of  blood  through  the  narrowed  tubes  et  ainsi  de 
suite.1 

Modern  pathologists,  however,  regard  arterio-scler- 
osis  as  a  wide-spread  process  affecting  the  arterio- 
capillary  system  generally,  causing  increased  resist- 
ance to  the  flow  of  blood  and  compensatory 
hypertrophy  of  the  left  ventricle.  These  two  con- 
ditions— increased  pressure  and  cardiac  hypertrophy 
— are  progressively  reciprocal,  the  cardiac  hyper- 
trophy being  a  necessary  physiological  adaptation  to 
meet  the  increasing  peripheral  resistance.  On  the 
other  hand  the  resulting  high  arterial  pressure  leads 
to  an  increasing  strain  on  the  walls  of  the  aorta 
and  on  the  arterio-capillary  system  generally.  Thus 
the  arterial  lesion  may  be  both  the  cause  and  effect 
of  the  hypertension. 
Warfield  wrrites  : 

"  Prolonged  hypertension  is  not  a  normal  state,  and 
sooner  or  later  there  must  result  changes  in  the  circula- 
tory system.  Changes  actually  do  occur  in  both  the 
heart  and  the  arteries,  leading  to  the  production  of 
arterio-sclerosis  and  to  the  establishment  of  a  Vicious 
Circle." 

1  H.  Gilford,  Disorders  of  Post-natal  Growth  and  Develop- 
ment, p.  346.  Cf.  also  Barr,  British  Med.  /.,  1905, 
I-,  P-  53- 


Carbio^Dasculnr  System  57 


And  again  : 

"  The  primary  change  is  an  increased  tension  in  the 
arterioles  which  later  leads  to  thickening  of  the  coats 
of  the  vessels  and  to  the  other  consequences  of  arterial 
disease.  A  Vicious  Circle  is  thus  established  which 
has  a  tendencjr  to  become  progressively  worse."1 

In  the  later  stages  of  arteriosclerosis  the  cardiac 
hypertrophy  undergoes  decompensation  and  the 
circular  reactions  already  described  on  p.  35  are 
established. 

Aneurysm.  Aneurysm  is  frequently  due  to  dis- 
ease of  the  arterial  walls,  which  consequently  grow 
weak  and  yield  to  the  blood-pressure.  The  more 
they  yield  the  greater  the  tension  ;  the  greater 
the  tension,  the  thinner  and  weaker  do  they  become. 
The  dilatation  is  progressive.2 

When  rupture  occurs  a  similar  reciprocation  is 
established  as  has  been  alluded  to  in  cases  of  rupture 
of  the  heart.  The  haemorrhage  paradoxically  raises 
the  blood-pressure,  death  resulting  from  general 
anaemia.  An  illustrative  case  is  described  by  Hensen 
in  which  an  aneurysm  of  the  descending  aorta 
perforated  the  left  bronchus  and  on  three  occasions 
gave  rise  to  profuse  haemoptysis.  Careful  measure- 
ments of  the  blood-pressure  showed  that  while 
the  pressure  just  before  an  attack  was  115  mm.  Hg, 
it  had  risen  to  142  mm.  a  quarter  of  an  hour  later. 
The  patient  survived  the  severe  attack  of  haemopty- 
sis, probably  owing  to  the  perforation  being  closed 

1  Arterio-sclerosis,  pp.  87,  113,  133,  163.     Cf.  also  Allbutt 

and  Rolleston,  S3^stem  of  Medicine,  VI.,  pp.  60 1,  606  ; 
Barr,  British  Med.  /.,  1909,  II.,  p.  61  ;  Oliver, 
British  Med.  /.,  1910,  II.,  p.  1333  :  Faught,  Blood- 
Pressure,  p.  285. 

2  If  t  stands  for  tension,  r  for  radius,  and  p  for  blood-pressure, 

then  t  =  •£  rp,  i.e.  with  a  constant  blood-pressure  the 
tension  increases  with  the  calibre  of  the  vessel. 


58  IDicfoud  Circles  in  Disease 

by  a  clot,  but  died  shortly  afterwards  from  a  recur- 
rence of  the  bleeding.1 

Varicose  Veins  and  Lymphatics.  Another  com- 
plication is  associated  with  varicose  veins,  whether 
these  are  due  to  increased  intra- venous  pressure 
or  to  diminished  resisting  power  of  the  vein-walls 
((Mate  III.  e).  In  either  case  the  dilatation  leads  to 
increased  tension,  and  the  tension  increases  the 
dilatation.  Incompetence  of  the  valves  constitutes 
a  further  aggravating  factor. 

Romberg  writes  : 

"  The  venous  dilatation  (due  to  some  mechanical 
obstruction)  and  the  anatomical  changes  in  the  vein- 
walls  act  reciprocally  on  one  another.  Thus  a  circulus 
vitiosus  whose  pathogenesis  is  obscure  controls  the 
course  of  events."2 

Lymphangiectasis  stands  the  same  relation  to  the 
lymphatic  system  as  does  venous  varicosis  to  the 
vascular.  When  lymphatics  are  unable  to  empty 
themselves  they  are  easily  stretched  and  weakened. 
The  dilatation  is  thus  progressive,  especially  when 
complicated  by  incompetency  of  the  valves.3 

ft  Capillary  Stasis.  According  to  Cohnheim  a 
"  most  pernicious  circulus  vitiosus  "  may  be  present 
when  local  inflammation  leads  to  capillary  stasis 
and  coagulation,  at  any  rate  if  the  injury  is  so 
severe  that  complete  repair  is  impossible.  The 
inflammatory  process  leads  to  stasis  and  the  stasis 
aggravates  the  inflammation.4 

lDeutsches    Archiv  /.   klin.   Medicin    (1900),   LXVII.     p. 

497; 

2  Krankheiten  des  Herzens  und  der  Blutgefasse,  p.  496.     Cf. 

also  Nobl,  Der  Varicose  Symptomencomplex,  p.  54. 
3Busey,  Narrowing,  Occlusion  and  Dilatation  of  Lymph 

Channels,  p.  116. 
4  General  Pathology,  I.,  pp.  339,  374-5. 


CarfcioDaecular  System  59 

The  successive  changes  which  take  place  in  a 
tissue  as  a  response  to  injury  are  (a)  dilatation  of 
the  blood-vessels,  (b)  acceleration  followed  by 
retardation  of  the  blood-stream,  and  (c)  emigra- 
tion of  leucocytes  and  erythrocytes.  These  and  the 
associated  conditions  are  beneficent  reactions  and 
suffice  under  ordinary  circumstances  to  repair  the 
damage.  The  inflammatory  process  undergoes  reso- 
lution and  is  followed  by  a  restitutio  ad  integrum. 

Where,  however,  the  trauma  is  severe,  graver 
sequelae  shew  themselves  ;  the  circulation  may  come 
to  a  complete  standstill,  the  vessel-walls  cease  to  be 
nourished,  the  contained  blood  coagulates  and  the 
surrounding  tissues  perish.  The  products  of  tissue 
death  and  disintegration  then  become  sources  of 
irritation  and  perpetuate  the  inflammation. 

At  the  outset  such  a  damaged  tissue  is  invaded 
by  crowds  of  leucocytes  which  multiply  rapidly  and 
combine  with  the  exudation  to  cause  swelling  and 
tension.  By  this  means  the  circulation  is  further 
checked,  nutrition  suffers,  and  the  area  of  necrosis 
may  be  extended.1 

Moreover  pyogenic  cocci  usually  make  their 
appearance,  introduced  either  through  a  wound  or 
derived  from  the  blood.  Many  are  destroyed  by 
phagocytosis  ;  but  should  their  numbers  be  too 
great  or  should  phagocytic  activity  be  impaired, 
the  invaders  find  in  the  clotted  blood  a  favourable 
medium  for  growth  and  proliferation.  The  resulting 
chemical  products  in  their  turn  intensify  the  inflam- 
matory processes.  Copious  exudations  of  serum 

*In  some  forms  of  inflammation,  such  as  that  met  with  in 
gas  gangrene,  the  bacillus  aerogenes  or  the  bacillus 
perfringens  causes  the  development  of  much  gas 
which  aggravates  the  stasis.  These  microbes  may 
also  produce  a  condition  of  acidsemia  which  in  turn 
favours  their  growth.  Lancet,  1916,  II.,  pp.  144, 
1063;  1918,  I.,  208. 


60  Dicious  Circles  in  H>iseaec 

are  poured  out  and  in  such  serum  float  both  the 
dead  leucocytes  that  have  perished  in  the  struggle 
with  the  invaders  and  the  fresh  leucocytes  which 
are  continually  hastening  to  the  field  of  battle. 

As  a  result  of  these  changes  the  exudations 
gradually  change  into  the  fluid  known  as  pus  and 
tend  to  collect  in  an  abscess  cavity.  Such  pus,  on 
the  one  hand,  contains  phagocytic  cells  and  pro- 
teolytic  enzymes,  which  assist  the  damaged  tissue 
in  its  struggle  for  repair.  On  the  other  hand  there 
are  also  present  bacterial  products  which  aggravate 
the  inflammation.  Moreover  the  proteolytic  enzymes, 
while  useful  in  destroying  necrosed  tissues,  may  at 
the  same  time  be  injurious  to  adjacent  tissues  of 
low  vitality  and  actually  cause  their  liquefaction. 
This  explains  how  it  is  that  pus  often  causes  rapid 
destruction  of  the  damaged  tissues,  which  tissues 
in  their  turn  supply  nutriment  to  the  micro-organisms 
and  thus  increase  the  formation  of  pus.  Indeed  the 
pus  acts  much  as  if  it  were  a  dead  tissue  in  a  state  of 
decomposition  and  may  cause  as  much  irritation  as 
would  a  foreign  body.  In  other  words,  when  once 
formed,  pus  feeds  itself  by  liquefying  the  tissues 
round  it — by  perpetuating  the  very  conditions  in 
which  it  originated.  Thus  is  established  one  of  the 
most  important  Vicious  Circles  in  pathology,  and, 
generally  speaking,  pus  must  be  evacuated  before 
recovery  can  take  place.  The  subject  is  further 
discussed  in  Chapter  XX. 

Capillary  stasis  is  a  prominent  factor  in  frostbite, 
and  results  from  a  variety  of  causes  such  as  cold, 
wet,  exhaustion  and  prolonged  standing,  conditions 
which  operate  powerfully  in  trench  warfare  when 
soldiers  have  to  stand  in  ankle- deep  mud  and  slush. 
In  the  worst  cases  the  blood-vessels  may  be  so 
narrowed  that  the  part  affected  is  blanched.  Such 
stasis  and  the  associated  lowered  vitality  allow  a 
still  greater  fall  of  temperature  which  may  end  in 
gangrene. 


CarbtcMDascular  System  61 

When  tight  boots  are  worn  there  is  further  inter- 
ference with  the  circulation,  leading  to  swelling 
of  the  feet  which  in  its  turn  increases  the  pressure 
of  the  boots. 

IvOUghnane  writes  : 

"  In  regard  to  boots  a  Vicious  Circle  develops.  The 
wet  leather  shrinks  and  presses  on  the  feet,  thereby 
setting  up  traumatic  inflammation  and  swelling,  which 
swelling  in  turn  increases  the  pressure  from  the  boots."1 

VI.     THE    BLOOD 

Disorders  of  the  blood  are  of  the  first  importance 
from  the  point  of  view  of  circular  reactions  since 
there  is  the  closest  interdependence  between  it  and 
every  other  tissue.2 

In  health  the  blood  is  subject  to  daily  and  hourly 
variation  as  regards  volume,  composition,  velocity, 
specific  gravity,  viscosity  and  so  forth.  Never- 
theless it  remains  essentially  the  same,  ever  ready 
to  supply  nutriment,  to  remove  waste,  to  protect 
against  bacterial  invaders  and  to  neutralise  injurious 
toxins.  Its  efficiency  is  maintained  by  a  self- 
regulating  mechanism  which  is  in  .ceaseless  operation 
and  by  means  of  which  variations — chemical, 
physical,  histological  or  biological — are  rapidly 
remedied.3  In  other  words  variation  evokes  a 
beneficent  reaction  of  the  nature  and  strength 
required  to  restore  the  disturbed  equilibrium.  In 
disease  this  self -regulating  mechanism  is  upset. 
Many  reactions  become  excessive,  overshoot  the 
mark,  and  aggravate,  in  lieu  of  remedying,  the 
disorder. 

1  Lancet,  1915,  I.,  p.  803. 

2  Fuller  details  will  be  found  in  Vicious  Circles  associated 

with  Disorders  of  the  Blood,  by  J.B.H.,  Practitioner, 
1916,  I.,  p.  621. 

3Achard,    Le    Mecanisme    Regulateur    du    Sang,    Presse 
Medicate,  1901,  II.,  p.  133. 


62  IDicioug  Circles  in 


Anaemia.  Various  disorders  originate  in  an  impo- 
verished supply  of  blood  to  organs  and  tissues. 
For  instance,  when  the  blood  supplying  the  stomach 
is  deficient  in  nutritive  elements,  the  digestive 
fluids  are  deficient  in  potency,  and  in  their  turn 
keep  the  blood  impoverished*  (JMatC  HI.  f).  The 
sequence  is  much  the  same  whether  the  disorder 
starts  with  anaemia  or  with  the  gastric  disorder. 
Robson  Roose  writes  : 

"  Blood  in  which  some  of  the  normal  constituents 
are  defective  will  not  yield  proper  secretions,  and  thus 
the  food  will  be  liable  to  be  imperfectly  acted  upon. 
In  this  way  a  Vicious  Circle  readily  becomes  established, 
inasmuch  as  the  secretions  themselves  are  dependent 
on  the  pabulum  which  the  blood  receives  through  the 
instrumentality  of  the  assimilating  organs."1 

Anaemia  is  frequently  associated  with  fatty  degen- 
eration of  the  endothelial  cells  of  the  blood-vessels  ; 
such  degeneration  may  give  rise  to  haemorrhage 
which  aggravates  the  condition. 

Cabot  writes  : 

"  To  the  fatty  degeneration  of  the  endothelial  cells 
of    the    blood-vessels    may    be    attributed    the    fact 
that  in  many  anaemic  conditions  a  general  hsemorrhagic 
diathesis  develops,   which  not  infrequently  combines 
with  the  primary  disease  to  form  a  Vicious  Circle."2 
In  other  cases  haemogenesis  is  paralysed.     Blood 
impoverished  of  haemoglobin  cannot  properly  nourish 
bone-marrow;  hence  blood-formation  flags. 
Buchanan  writes  : 

"  Haemorrhage  is  an  obvious  cause  of  blood  loss  or 
drain  and  is  rapidly  recovered  from  when  sudden  and 
profuse  within  limits.  But  continued  and  intermittent 

1  Nerve    Prostration,    p.    492.     Cf.    also    Buchanan,    The 

Blood  in  Health  and  Disease,  p.   164  ;    Trousseau, 
Clinical  Medicine,  II.,  p.  383  ;  V.,  p.  109. 

2  Diseases  of  Metabolism  and  of  the  Blood,  p.  308. 


CarbfolDascular  System  63 

and  small  haemorrhages  from  the  mucous  surfaces  may 
produce  an  anaemic  state  which  may,  from  lack  of 
recuperative  power  of  the  haemogenetic  tissues,  become 
'  progressive  '  and  fatal.  It  is  quite  conceivable  that 
here  a  Vicious  Circle  is  established,  so  that  the  impover- 
ished state  of  the  blood  itself  increases  the  tendency  to 
haemorrhage  which  originally  produced  it."1 

Pernicious  anaemia  is  probably  due  to  paralysis 
of  the  haematopoietic  organs,  associated  with  dimin- 
ished resisting  power  of  the  newly  formed  blood. 
These  two  factors — disordered  blood  formation  and 
increased  blood  consumption — react  injuriously  on 
one  another  and  often  bring  about  a  fatal  issue. 

Eichhorst  writes  : 

"  A  Vicious  Circle  may  be  formed,  when  once  dis- 
ordered blood-formation  or  increased  blood-destruction 
has  given  rise  to  marked  anaemia  of  the  common  kind. 
For  not  only  does  the  disordered  blood-formation  cause 
less  blood  to  be  formed,  but  the  smaller  quantity  of 
newly  formed  blood  also  possesses  less  resistance  and 
is  therefore  more  readily  used  up.  Thus  the  two 
components  of  disordered  blood  formation  and  increased 
blood  consumption  act  injuriously  on  one  another  and 
combine  to  bring  about  a  rapidly  fatal  issue."2 

Anhydraemia.  Anhydraemia  such  as  is  associated 
with  cholera  establishes  some  correlations  which 
are  closely  connected  with  the  fatality  of  the  disease. 
As  a  result  of  the  profuse  evacuations,  which  may 
amount  to  eight  or  more  pints  within  a  short  period, 
the  blood  sometimes  loses  more  than  half  its  fluid 
contents.  Such  loss  is  accompanied  by  a  danger- 
ously low  blood-pressure,  which  sometimes  falls  as 

1  The  Blood  in  Health  and  Disease,  p.  164. 

2 Turk,  Klinische  Hsematologie,  II.  (ii.),  p.  379.      Cf.  also 

Pick  and  Hecht,  Clinical  Symptomatology,  p.  494  ; 

The  Mayo  Clinic  (1916),  VIII.,  p.  620. 


64  IMcioug  Circles  in  2)tseage 

low  as  50  mm.  Hg.1  This  low  pressure,  combined 
with  the  increased  viscosity  and  the  swelling  of  the 
renal  epithelium,  leads  to  suppression  of  urine  and 
to  an  accumulation  of  the  toxins,  which  then  per- 
petuate the  disease.  Thus  the  anhydrsemia  and 
anuria  reciprocally  aid  and  abet  one  another. 

Carbonaemia.  Determann  has  drawn  attention 
to  a  complication  of  carbonaemia  (i.e.  an  excess  of 
CO2  in  the  blood)  due  to  the  fact  that  excess  of 
CO2  increases  the  viscosity  and  vice  versa.  The 
reciprocation  is  thus  described  by  Allbutt  : 

"  Carbon  dioxide  is  the  most  important  of  all  the 
factors  of  viscosity,  for  the  changes  in  viscosity  by 
these  gases  (i.e.  COz  and  O)  are  less  of  the  plasma 
than  of  the  corpuscles.  Hence  in  diseases  of  the  heart 
and  lungs  a  Vicious  Circle  is  established  of  plus  viscosity, 
plus  resistance,  plus  CO2,  and  so  round  to  plus  viscosity 
again — a  gyration  which  the  heart  may  be  unable,  by 
increasing  the  pressure  head,  to  break  through."2 

This  condition  of  carbonsemia  is  often  the  cause 
of  death  through  a  gradual  interference  with 
oxygenation.  Ritchie  thus  refers  to  the  process  : 

"  Usually  the  act  of  dying  is  prolonged  over  a  con- 
siderable number  of  hours  and  at  the  commencement 
there  frequently  appear  disorders  of  respiration,  which 
are  indications  either  of  oxygen-hunger  or  of  the  com- 
mencing accumulation  of  carbonic  acid.  .  .  .  The 
essential  point  is  a  progressive  failure  of  the  heart  and 
respiration  in  which  each  downward  step  in  the  capacity 
of  one  system  is  reflected  in  a  corresponding  downward 

1  In  severe  attacks  Rogers  found  that  the  loss  of  fluid  from 

the  blood  amounted  to  64  per  cent.  Cholera  and  its 
Treatment,  p.  149. 

2  Determann,    Die    Viscositat    des    menschlichen    Blutes, 

p.  80.  Cf.  also  Allbutt,  Diseases  of  the  Arteries, 
I.,  pp.  129,  130,  153  ;  Hirschfelder,  Diseases  of  the 
Heart  and  Aorta,  p.  41. 


CarfctcMDascular  System  65 

step  in  the  functions  of  the  other.  The  supply  of 
blood  to  the  lungs  by  the  heart  is  diminished,  and 
frequently  this  leads  to  oedema  of  the  organs.  The 
coating  of  the  alveolar  epithelium  with  fluid  interferes 
with  the  interchange  of  oxygen  between  the  air  and 
the  blood  ;  the  heart  is  thus  supplied  with  a  deficiently 
oxygenated  blood,  its  inherent  weakness  is  thus  in- 
creased and  at  the  same  time  the  respiratory  and 
cardiac  centres  in  the  medulla  have  their  controlling 
functions  perverted.  The  Vicious  Circle  established 
increases  progressively  in  severity  of  effect,  and  finally 
the  heart  comes  to  a  standstill."1 

Other  Circles  associated  with  an  accumulation  of 
CO2  are  referred  to  in  the  Chapter  dealing  with 
respiratory  disorders. 

Polycythaemia.  Some  interesting  correlations 
may  be  connected  with  polycythaemia,  a  condition  in 
which  the  red  blood  disks  may  be  increased  to 
10,000,000  in  the  cmm.  or  even  more.  The  increased 
viscosity  tends  to  produce  some  degree  of  blood 
stasis,  and  this  in  its  turn  favours  the  occurrence  of 
thrombosis  in  the  various  viscera,  thus  further 
hampering  the  circulation.  Again,  retarded  circula- 
tion and  congestion  in  the  blood-vessels  of  the  lungs 
promote  the  development  of  chronic  catarrhal 
changes,  which  induce  cyanosis  and  throw  extra  work 
on  the  right  side  of  the  heart.  Thus  complex 
reactions  are  established  ;  the  polycythsemia  tends 
to  impede  the  circulation,  and  the  resulting  blood 
stasis  produced  gives  rise  to  a  further  polycythsemia.2 

Another  complication  is  sometimes  observed  in 
polycythsemia,  a  disorder  in  which  increased  form- 
ation and  increased  destruction  of  red  disks  act 
and  react  on  one  another. 

1Pembrey  and  Ritchie,  General  Pathology,  p.  759. 
2Parkes  Weber,   Quarterly  J.   of  Medicine    (1908-9),   II., 
p.  112. 


66  iDicious  Circles  in  Bisease        

Ward  writes  : 

"  The  increase  of  red  cells  is  the  primary  feature,  so 
far  as  we  can  tell.  This  increases  the  viscosity  of  the 
blood  and  there  is  an  increase  of  volume  in  order  to 
relieve  the  viscosity.  To  this  most  of  the  symptoms 
would  appear  to  be  due.  A  further  mechanical  attempt 
of  Nature  to  deal  with  the  difficulty  that  she  has 
initiated  is  increased  destruction  of  red  cells.  This  is 
shewn  by  the  dark  colour  of  the  urine  and  the  presence 
in  it  of  urobilin.  Unfortunately  the  stimulus  of  blood 
destruction  inevitably  leads  to  fresh  blood  formation, 
so  that  we  very  soon  have  a  Vicious  Circle.  The  total 
result  seems  usually  to  be  inimical  to  the  patient  and 
the  polycythsemia  is  steadily  progressive.  Arterial 
degeneration  follows  the  increased  blood-pressure, 
which  depends  in  turn  on  the  increased  heart  work 
necessary  to  drive  round  the  body  the  highly  viscous 
blood.  This  arterial  affection  often  leads  to  death 
and  the  termination  of  the  pathological  process."1 

There  are  a  number  of  cardiac  and  respiratory 
diseases  in  which  stagnation  in  the  pulmonary 
capillaries  and  the  associated  deficient  oxygenation 
give  rise  to  polycythsemia  and  increased  viscosity, 
which  in  their  turn  intensify  the  stagnation.  Similar 
conditions,  by  throwing  an  extra  burden  on  the 
heart,  are  apt  to  impair  the  efficiency  of  the  elimina- 
ting organs  and  thus  perpetuate  the  condition.2 

Thyreo-Globinaemia.  Some  pathologists  believe 
that  an  injurious  circular  reaction  may  be  established 
in  cases  of  hyperthyroidism,  due  to  the  presence  of 
thyreo-globulin  in  the  blood.  The  increased  quan- 
tity of  blood  passing  through  the  thyroid  causes  an 
increased  secretion  of  thyreo-globulin  and  this  in  its 
turn  causes  more  blood  to  pass  through  the  thyroid. 
Thus  the  thyroid  epithelium  is  activated  by  its  own 
product,  which  returns  to  it  through  the  blood. 

Bedside  Haematology,  p.  156. 
2  Ward,  I.e.,  p.  182. 


CarbicMPaacular  System  67 

Hirschf elder  thus  represents  the  sequence  : 1 

Hyperthyroidism, 
(Basedow's  disease) 


Increased  thyroid  « «g    Increased  blood  flow 

secretion  through  thyroid 

According  to  Oswald  an  abnormally  irritable 
nervous  system  is  the  principal  factor  that  stimulates 
the  thyroid  and  is  in  its  turn  stimulated  by  the 
thyroid  secretion.2 

Thyroid  insufficiency  may  also  establish  a  recipro- 
cation in  which  subthyroidism,  weakened  peristalsis, 
constipation,  toxaemia  and  progressive  thyroid  inade- 
quacy constitute  the  factors.  "  Once  the  toxaemia 
is  established,  a  Vicious  Circle  is  formed."3 

Toxaemia.  Many  circular  reactions  are  created 
in  the  course  of  toxaemia.  For  instance,  coprostasis 
in  many  persons  is  followed  by  the  absorption  of 
toxins,  which  weaken  peristalsis  and  maintain  the 
stasis. 

E.  von  Ofenheim  writes  : 

"  The  question  is  what  is  the  effect  of  the  stasis  on 
the  bacteria,  and  vice  versa  of  the  bacterial  toxins 
on  the  stasis  ?  It  has  repeatedly  been  proved  that 
a  Vicious  Circle  exists  between  them.  Stasis  causes 


1  Diseases  of  the  Heart  and  Aorta,  1913,  pp.  682-3,  689-91. 
2 Oswald    (Zurich),    Ueber   den   Morbus   Basedow,    Corres- 

pondenz-Blatt  /.  Schweizer  Aerzte,  1912,  p.  ir44.     Cf. 

also  Wells,  Chemical  Pathology,  p.  606. 
3Hertoghe,    Thyroid    Insufficiency,    Practitioner,    1915,    I., 

pp.   54-5,   66.     Cf.    also  McCarrison,   The  Thyroid 

Gland,  pp.  138,  188. 


68  IDidous  Circles  in  SDisease 

bacterial  poisons  to  be  formed  ;  these  poisons,  again, 
have  a  paralysing  effect  on  the  intestines,  and  in  this 
way  add  to  the  stasis."1 

Uraemia.  The  term  uraemia  includes  various 
complex  disorders  which  supervene  in  the  course 
of  renal  disease,  and  whose  pathology  is  still  obscure. 
But  at  least  some  of  these  disorders  are  due  to  the 
renal  interference  with  the  elimination  of  toxins 
which  therefore  accumulate  in  the  blood  and  in  turn 
aggravate  the  renal  condition. 

The  exact  nature  of  the  poisons  concerned  is  still 
unknown,  but  they  are  probably  related  to  the 
antecedents  of  urea  in  the  chain  of  metabolic 
processes. 

Another  view  is  that  the  renal  cells  under  certain 
conditions  may  themselves  manufacture  poisonous 
substances,  known  as  nephrolysins,  which  in  their 
turn  perpetuate  the  renal  disorder. 

Chauffard  and  lysederich  write  : 

"  There  can  be  no  doubt  that  certain  alterations  in 
the  renal  cells  may  give  rise  to  toxic  matters,  which 
in  their  turn  perpetuate  these  alterations  and  create 
a  true  Vicious  Circle,  the  effect  of  which  is  a  more  or 
less  indefinite  continuance  of  the  nephritis."2 

Eclampsia  may  be  similarly  complicated. 

Wells  writes  : 

"  A  reasonable  view  of  the  cause  of  eclampsia  is 
that  it  is  initiated  by  the  excessive  products  of  meta- 
bolism thrown  into  the  blood  of  the  mother,  both 
from  the  fetus  and  from  her  own  over-active  tissues. 
These  cause  injury  to  the  kidneys,  leading  to  a  further 

1Proc.  Royal  S.  of  Medicine   (1913),  VI.    (i.),  (Alimentary 

Tox&mia),  p.  326. 
2Brouardel  and  Gilbert,  Maladies  des  Reins,  p.   166.     Cf. 

also   Osier  and   Macrae,  System  of  Medicine,    III., 

834  ;     J.   A.    Kolmer,     Infection,     Immunity     and 

Specific   Therapy,   p.   505. 


System  69 


retention,  or  injure  the  liver  so  that  the  normal  metabo- 
lic processes  of  that  organ  (particularly  oxidation) 
cannot  be  carried  on  ;  or  perhaps  more  often  both 
liver  and  kidney  as  well  as  other  organs  are  injured. 
In  this  way  a  Vicious  Circle  might  be  established  and 
rapidly  lead  to  an  overwhelming  of  the  maternal  system 
with  toxic  products  derived  from  both  her  own  and 
the  fetal  tissues."1 

Uricaernia.  Injurious  reciprocations  may  some- 
times occur  when  excess  of  uric  acid  in  the  blood  is 
caused  by  inadequacy  of  hepatic  metabolism  and 
associated  with  calculous  nephritis. 

For  example,  if  from  some  cause  or  other  the 
liver  does  not  produce  sufficient  uricolytic  enzyme 
to  transform  all  the  uric  acid  reaching  it  into  urea, 
an  excess  of  that  acid  passes  into  the  blood  and 
reaches  the  kidney,  where  some  of  it  is  deposited 
in  the  renal  pyramids.  In  this  way  calculous  de- 
posits are  liable  to  form  and  to  give  rise  to  a  secondary 
chronic  nephritis  (nephrite  lithiasique). 

As  a  result  of  this  nephritis  there  will  be  a  lessened 
internal  secretion,  and  this  in  turn  causes  lessened 
uricolytic  enzyme  in  the  liver. 

Uricsemia  also  perpetuates  itself  as  a  result  of 
increased  viscosity  of  the  blood  due  probably  to  the 
presence  of  an  excess  of  urates  in  a  colloid  form. 
There  results  obstruction  in  the  capillaries,  leading 
to  a  further  accumulation  of  the  products  of  imper- 
fect metabolism. 

Gilbert  writes  : 

"  Capillary  obstruction  may  in  this  way  eventuate 
in  an  '  ill-burning  fire,'  in  which  the  purin  ashes  of 
nitrogenous  combustion  (xanthin  and  uric  acid)  are 


Chemical  Pathology,  p.  487.  Cf.  also  Eden,  Midwifery, 
pp.  iT2,  120,  123  ;  Musser  and  Kelly,  Practical 
Treatment,  III.,  p.  634. 


70  IDicioue  Circles  in  ^Disease 

retained  and  accumulate  to  cause  further  obstruction, 
thus  tending  to  form  a  circulus  vitiosus."1 

According  to  Haig  whose  views,  however,  are  by 
no  means  generally  accepted,  various  other  compli- 
cations may  be  associated  with  an  excess  of  uric 
acid  in  the  blood,  and  these  produce  a  condition 
known  as  collaemia.  For  example,  collaemia  and 
dyspepsia  are  reciprocally  correlated.2 

Further  circular  reactions  such  as  those  associated 
with  cholaemia,  hyperglycsemia  will  be  described  in 
other  Chapters  (Cf.  Index). 


"  Uric  Acid,"  XIII.,  L,  p.  22. 

2  Uric    Acid   as    a   Factor  in    the   Causation    of    Disease, 
pp.  242,  405,  407. 


Chapter 


THE    RESPIRATORY    SYSTEM 


HE  tipper  portion  of  the  respiratory  tract 
including  the  nose  and  throat  will  be 
dealt  with  in  subsequent  Chapters.  We 
shall  deal  here  with  : 

I.     The  Lungs 

II.     The  Pleura 

III.     The  Bronchi 

I.     THE   LUNGS 

Pneumonia.  An  injurious  circular  reaction  is 
frequently  met  with  in  pneumonia,  owing  to  the 
reciprocal  embarrassment  of  the  heart  arid  lungs. 
The  great  strain  imposed  on  the  right  ventricle  is 
partly  due  to  the  impeded  pulmonary  circulation 
and  deficient  aeration  and  partly  to  the  action  of 
toxins,  and  frequently  leads  to  dilatation  and  failure. 
When  such  failure  supervenes,  the  weakened  myocar- 
dium further  impairs  both  pulmonary  circulation 
and  oxygenation,  the  primary  trouble  being  thus 
re-enforced  (JMatC  IV.  a). 
Frankel  writes  : 

"  The  heart  thus  gets  into  a  circulus  vitiosus,  since 
the  blood  stasis  causes  a  further  diminution  in  the 
supply  of  oxygen  on  which  the  increased  cardiac 
activity  depends."1 

This  process  of  reciprocation  is  especially  grave 
when  the  heart  is  unsound  to  begin  with  ;  then 
the  patient  is  indeed  inter  malleum  et  incudem. 

1  Lungenkrankheiten,  p.  300.     Cf.   also  Lancet,   1874,  II., 
p.  682. 

71 


72         iDicious  Circles  in  Disease 

Pneumonia  affords  a  good  illustration  of  what 
may  be  called  an  "  organic  "  Circle,  i.e.  one  which 
arises  from  the  interdependence  of  two  organs.  For 
a  time  the  congested  lung  is  vicariously  aided  by 
increased  cardiac  activity.  But  if  too  great  a  strain 
is  imposed  on  the  heart,  this  organ  in  its  turn  is 
weakened  and  reacts  injuriously  on  the  lungs  which 
are  finally  undone  by  conditions  created  by  them- 
selves and  for  their  own  temporary  advantage.  A 
similar  interdependence  is  present  in  all  serious 
disorders  both  of  the  heart  and  of^the  lungs. 

Tuberculosis.  Pulmonary  tuberculosis  is  compli- 
cated by  a  variety  of  injurious  reciprocations  which 
play  an  important  share  in  the  perpetuation  and 
fatality  of  the  disease.  Only  a  few  examples  can  be 
given  here  ;  for  further  details  reference  may  be 
made  to  a  special  article.1 

The  lowered  resistance  which  so  frequently  results 
from  tubercular  infection  plays  a  great  part  in  the 
extension  of  the  disease.  Such  lowered  resistance  or 
hyper-susceptibility  to  fresh  infection  within  certain 
limits  is  a  protective  reaction,  which  tends  to  repel 
infection  and  localize  disease.  Bxtreme  hyper-sus- 
ceptibility, however,  causes  grave  toxaemia  through 
excessive  auto-intoxication,  followed  by  a  subnormal 
opsonic  index  and  aggravation  of  the  disease.  In 
other  words  the  machinery  of  immunization  is 
paralysed,  resulting  in  a  further  accumulation  of 
toxins,  these. two  factors  abetting  one  another. 
Thomson  describes  the  process  : 

"  In  a  large  proportion  of  cases  cure  by  spontaneous 
auto-inoculation  does  not  take  place.  The  reason  for 
this  is  two-fold.  The  protective  influence  instead  of 
being  stimulated  is  paralysed,  so  that  we  have  estab- 
lished a  Vicious  Circle  which  favours  active  progress 
of  the  disease.  On  the  other  hand,  owing  to  the  latent 

1  Pulmonary  Tuberculosis  and  its  Vicious  Circles,  by  J.B.H., 
Practitioner,  1914,  I.,  p.  274. 


IRespiratorp  System 


73 


(a)  PULMONARY  CONGESTION 


(b)  H/EMOPTYSIS 


> 


(c)  PULMONARY  TUBERCULOSIS        (d)  PLEURITIC  EFFUSION 


(e)  BRONCHIECTASIS 


(f)  ASTHMA 


plate  IV.— Circles  associated  with  the 
IRespiratorv  System. 


74  IDtcioug  (Eircleg  in  g>teease 

condition  of  the  disease  the  auto-inoculation  may  not 
be  sufficient  to  elicit  any  lasting  immunizing  response, 
in  consequence  of  which  healing  does  not  take  place, 
and  the  lesion  remains  quiescent,  though  ever  ready 
in  the  presence  of  some  favourable  influence  to  burst 
into  fresh  activity."1 

In  many  cases  loss  of  vitality  precedes  the  tuber- 
culous invasion,  but  the  further  sequence  of  events  is 
very  similar.  They  are  thus  described  by  Muthu  : 

"Bad  air  and  insufficient  food,  septic  mouth  and 
decayed  teeth,  adenoid  growths  and  naso-pharyngeal 
catarrh,  tonsillar  enlargements  and  cervical  and  other 
glandular  swellings,  scrofulous  diathesis  and  poor 
physical  development,  impaired  nutrition  and  lowered 
vitality,  all  form  a  Vicious  Circle  which  favours  the 
entrance  of  tubercle  and  other  germs  in  early  childhood, 
when,  if  they  do  not  develop  and  commence  active 
mischief,  they  lie  latent,  and  in  after  years  produce 
pulmonary  tuberculosis  of  adults."2 

Another  reciprocally  acting  disorder  is  associated 
with  haemoptysis  and  the  increased  blood-pressure 
caused  by  the  act  of  coughing  and  by  the  anxiety 
accompanying  the  appearance  of  blood  (JMatC  IV.  b). 
Psychic  conditions  may  send  up  the  pressure  by  as 
much  as  40  mm.  Hg  and  the  rise  may  be  further 
increased  by  paroxysms  of  cough  ;  such  increase 
tends  to  intensify  the  haemorrhage. 

Hare  writes  : 

"  In  phthisical  hsemoptysis  there  is  in  operation 
one  of  the  most  highly  Vicious  Circles  in  pathology — 
a  Circle  which  is  largely  responsible  for  the  profuseness 
and  prolongation  of  the  haemorrhage.  The  intra- 
pulmonary  irritation  of  the  effused  blood  causes  cough  : 
each  act  of  coughing,  like  any  other  sudden  exertion, 
causes  rise  of  blood-pressure  ;  each  rise  of  blood- 

1  Consumption  in  General  Practice,  p.  244.       Cf.  also  New 

York  Medical  /.,   1918,  II.,  p.  431. 

2  Pulmonary  Tuberculosis  and  Sanatorium  Treatment,  p.  60. 


System  75 


pressure  is  apt  to  cause  fresh  haemorrhage  and  so  on 
over  again,  the  Circle  continuing  to  revolve  in  many 
cases  until  the  loss  of  blood  has  been  sufficient  to  reduce 
the  blood-pressure  materially  and  thus  terminate  the 
haemorrhage.  This  natural  cure  of  haemoptysis  was, 
at  one  period  in  the  history  of  Medicine,  imitated  by 
physicians  who  resorted  to  venesection  in  this  emer- 
gency —  a  somewhat  expensive,  but  by  no  means 
irrational,  imitation,"1 

Pulmonary  tuberculosis  tends  to  extend  by  a 
process  of  auto-infection  when  a  tuberculous  patient 
re-inoculates  himself  with  sputa  discharged  from  a 
primary  lesion  in  the  lung.  Cough  forms  one  of 
Nature's  protective  mechanisms  since  infected  sputa 
are  thus  expelled.  At  the  same  time  it  is  attended 
with  much  danger  of  diffusing  infection,  for 
tubercle-laden  sputa,  when  loosened  by  cough,  are 
frequently  aspirated  into  healthy  parts  of  the  lungs 
and  there  set  up  fresh  foci.  Thus  disease  spreads 
from  lobe  to  lobe,  giving  rise  to  fresh  occasions  for 

cough  (plate  iv.  c). 

In  some  cases  sputa,  when  loosened  by  cough,  are 
swallowed  and  infect  the  alimentary  tract.  Thence 
the  bacilli  pass  through  the  lymphatics  and  reach 
the  lungs,  where  fresh  foci  are  started  and  further 
materials  for  cough  are  produced.2 

1  Food  Factor  in  Disease,  II.,  p.  97. 

2  Various  mechanisms  exist  by  which  bacilli  may  be  trans- 

ported from  one  part  of  the  body  to  another.  For 
example,  leucocytes  may  ingest  bacilli  and  yet  be 
unable  to  destroy  them  owing  to  an  insufficient 
supply  of  intra-cellular  antibodies.  The  bacilli  may 
then  be  transported  into  neighbouring  lymphatic 
vessels,  and  on  the  death  of  a  leucocyte  may  escape 
into  the  tissues,  like  the  Greeks  from  the  wooden  horse 
at  Troy.  In  other  cases  a  caseous  tubercle  may 
ulcerate  and  liberate  bacilli  into  a  blood-vessel 
Fresh  foci  of  disease  may  then  be  started  in  remote 
parts  of  the  body. 


76  IDictous  Circles  in  ^Disease 

Occasionally  the  incessant  cough  of  a  consumptive 
may  rob  him  both  of  sleep  and  of  morale,  and  this 
gives  rise  to  great  prostration.  This  like  every- 
thing that  exhausts  a  patient  favours  the  progress 
of  the  disease.  Again,  severe  cough  not  infrequently 
injures  lung  tissue  in  process  of  healing,  thus 
increasing  the  irritation.  Coughing  then  causes 
coughing. 

In  Judson's  words  : 

"  Coughing  increases  the  irritation,  and  the  irritation 
in   turn   increases   the   coughing.     This   is   a   Vicious 
Circle,  and  certainly  suggests  the  intervention  of  reason 
and  self -control."1 
Pottenger  also  writes  : 

"  Cough,  by  irritation,  increases  the  tendency  to 
cough,  and  by  increasing  secretion,  increases  the 
necessity  for  cough."2 

The  astonishing  rapidity  with  which  pulmonary 
cavities  sometimes  form  and  enlarge  is  due  to  the 
operation  of  circular  reactions.  An  entire  lung  may 
at  times  be  so  completely  destroyed  that  the  bronchi 
open  into  a  vast  cavity  bounded  by  little  more  than 
the  pleura.  The  disintegration  may  be  due  to 
various  causes.  For  instance,  a  mass  of  caseous 
tubercles  may  be  discharged  into  a  bronchial  tube, 
leaving  a  cavity  whose  walls  are  in  active  tuber- 
culous evolution.  The  larger  the  surface  exposed  to 
infection,  the  more  rapidly  does  erosion  proceed  ; 
the  cavity  thus  tends  to  grow  excentrically.  Again 
the  accumulation  of  stagnant  secretions  greatly 
favours  the  multiplication  both  of  the  tubercle 
bacilli  and  of  other  pyogenic  micro-organisms. 
These  mixed  infections  accelerate  the  advance  of 
the  tuberculosis  and  tend  to  the  further  enlargement 
of  the  cavities. 

International    Congress    on   Tuberculosis    at   Washington 

(1908),  II.,  p.  679.-  4ri    < 
2  Pulmonary  Tuberculosis,  p.  271. 


IReeptraton?  System  77 

Camac  Wilkinson  writes  : 

"  The  aetiological  diagnosis  must  take  into  account 
other  infections,  especially  the  common  infections  of 
the  air  passages.  These  infections  favour  tuberculosis 
and  tuberculosis  favours  these  infections.  This  Vicious 
Circle  of  tuberculosis  and  secondary  or  concurrent 
infections  may  play  an  important  part  even  in  the 
early  stages  of  pulmonary  tuberculosis,  though,  as  a 
rule,  those  unfortunate  accidental  complications  belong 
to  a  later  stage  of  the  disease."1 

Laryngeal  complications  may  also  have  an  impor- 
tant influence.  For  example,  the  forcible  propulsion 
of  sputa  against  the  vocal  chords  may  abrade  the 
laryngeal  epithelium  and  inoculate  the  abrasions. 
This  secondary  focus  may  then  become  a  fresh 
source  of  pulmonary  infection.  Dysphagia  and 
insomnia  are  often  aggravating  factors. 
Davis  writes  : 

"When  the  larynx  is  involved  a  Vicious  Circle  occurs, 
in  which  the  dysphagia,  sleeplessness  and  cough  pro- 
duced   by   the   painful    lesion   markedly  increase  the 
rapidity  of  the  progression  of  the  lung  condition."2 
In   some   cases  of  phthisis  secondary   dyspeptic 
disorders  accelerate  the  progress  of  the  disease. 
Barbier  writes  : 

"  These  visceral  troubles  add  to  the  wretchedness 
of  the  sufferer.  Not  only  are  they  caused  by  the 
tuberculosis,  but  they  accelerate  its  progress,  both  by 
diminishing  the  power  of  resistance  and  by  inducing 

other   complications   associated   with   tubercle 

Thus  is  established  in  all  its  mischievous  correlations 
that  Vicious  Circle  which  so  often  complicates 
phthisis."3 

1  Tuberculin  in  the  Diagnosis  and  Treatment  of  Tuberculosis, 

p.  94.     Cf.  also  Practitioner,  1913,  I.,  p.  157. 

2  Lancet,  1913,  II.,  p.  1112. 

3Brouardel  et  Gilbert,  Maladies  des  Bronches  et  des 
Poumons,  p.  495.  Cf.  also  New  York  Medical  /., 
1918,  II.,  p.  474. 


\Dicious  Circles  in  Disease 


These  are  a  few  of  the  conditions  in  which  pul- 
monary tuberculosis  tends  to  self-extension.  Equally 
important  are  the  social  disabilities  which  result 
from  and  in  turn  feed  the  disease.1 

Atelectasis.  In  weakly  infants  sudden  death 
sometimes  occurs  as  a  result  of  atelectasis  or  pul- 
monary collapse,  the  fatal  process  being  started  by 
what  at  first  appears  to  be  a  quite  trifling  catarrh. 
The  rapid  progress  of  the  disease  is  due  to  the  fact 
that  collapse,  once  begun,  supplies  the  cause  for  its 
further  increase.  On  the  one  hand  the  accumulation 
of  mucus  tends  to  increase  in  proportion  to  the 
diminution  in  the  amount  of  air  entering  the  lungs  ; 
on  the  other  the  increasing  impurity  of  the  blood, 
from  imperfect  aeration,  impedes  the  muscular  and 
nervous  functions  which  would  promote  the  expul- 
sion of  the  mucus. 

A  pernicious  factor  is  sometimes  brought  into 
operation  in  cases  of  dyspnoea  when  the  lower  ribs 
and  even  the  lower  end  of  the  sternum  are  drawn 
inwards  during  the  act  of  inspiration,  instead  of 
rising  in  the  usual  manner.  The  result  may  be  a 
local  pulmonary  collapse,  which  by  producing  fur- 
ther dyspnoea  may  stimulate  the  respiratory  activity, 
lead  to  greater  drawing  in  of  the  ribs,  and  thus 
aggravate  the  collapse.2 

(Edema.  Important  correlations  are  often  pre- 
sent in  soldiers  who  have  been  "gassed"  by  chlorine 
or  other  fumes  during  the  war.  According  to 
Schafer,  who  has  carefully  studied  the  condition,  the 
irritant  gas  gives  rise  to  acute  congestion  and  obstruc- 

1Cf.  Poverty  and  its  Vicious  Circles,  by  J.B.H.,  p.  40. 
2Fagge  and  Pye-Smith,  Text-Book  of  Medicine,  I.,  p.  1057. 

Cf.  also  Allbutt  and  Rolleston,  System  of  Medicine, 

III.,  pp.  89,  0,6. 


System  79 


tion  of  the  pulmonary  vessels  associated  with 
extensive  oedema  of  the  interstitial  tissues  of  the 
lung.  The  exuded  lymph  may  also  escape  into  the 
alveoli,  where  it  clots  and  thus  intensifies  the  obstruc- 
tion. . 
Schafer  writes  : 

"  Presumably  the  oedema  is  secondary  to  the  vas- 
cular obstruction,  but  even  if  this  is  so,  it  must  set 
up  a  Vicious  Circle  by  increasing  the  obstruction,  and 
this  again  will  increase  the  oedema,  so  that  in  cases 
of  survival  the  oedematous  condition  must  tend  to 
increase,  at  any  rate  for  some  time."1 

Respiratory  Inactivity.  A  variety  of  conditions 
are  met  with  in  which  oxygenation  is  impaired 
owing  to  defective  respiratory  activity,  and  such 
deficiency  tends  to  be  self  -perpetuating.  For  ex- 
ample, in  obesity  the  respiratory  muscles  and  ribs 
are  over-weighted  with  fat  and  unable  to  expand  the 
chest  efficiently  ;  moreover  the  thoracic  cavity  may 
be  encroached  upon  by  fatty  cushions  in  the  medi- 
astina  and  by  the  fatty  enlarged  heart.  The 
diaphragmatic  pump  may  be  unequal  to  forcing 
down  the  fatty  viscera  into  the  abdomen  which  is 
itself  encroached  upon  by  extensive  and  unyielding 
accumulations  of  fat.  In  brief,  both  the  respiratory 
capacity  of  the  chest  and  the  respiratory  move- 
ments of  the  lungs  are  diminished.  All  these  con- 
ditions tend  to  shallow  breathing  movements  and 
the  shallower  the  respiration  the  less  the  assistance 
given  to  the  return  of  venous  blood  to  the  heart  and 
lungs.  Further,  the  shallower  the  respiratory  move- 
ments, the  slower  is  the  rate  of  oxidation  ;  the 
fat-forming  substances  are  less  perfectly  burned  up 
and  are  more  largely  deposited  as  fat,  and  thus  the 
injurious  sequence  is  renewed.2 

1  British  Me.d.  /.,  1915,  II.,  pp.  246,  801. 
2Cf.  Obesity  and  its  Vicious  Circles,  by  J.B.H.,  Practitioner, 
1917,  II.,  p.  164. 


8o  \Dictou0  Circle0  in 


Feeble  respiratory  movements  from  any  cause 
whatever  tend  to  defective  nutrition  of  the  lungs, 
since  such  nutrition  depends  largely  on  adequate 
movements  ;  hence  defective  expansion  and  im- 
paired nutrition  act  and  react  on  each  other.  In 
fact  feeble  movements  of  the  chest  walls  are  in- 
jurious in  many  directions.  Even  ansemia  may  be 
due  to  this  cause. 

"  The  patient  lies  in  the  Vicious  Circle  of  a  reduced 

activity  of  the  respiratory  centre,  due  to  the  anaemia 

it  should  help  to  dispel."1 

This  conclusion,  however,  seems  questionable  ; 
frequently  ansemia  has  the  opposite  effect. 

Asphyxia.  Defective  oxygenation  as  met  with 
in  asphyxia  is  often  associated  with  self  -aggravating 
conditions.  The  primary  effect  is  increased  respi- 
ratory activity  which  tends  to  compensate  for  the 
defect.  If,  however,  such  increased  activity  brings 
no  relief  the  venosity  of  the  blood  increases,  blood- 
pressure  rises  and  the  heart  is  slowed  by  the  cardio- 
inhibitory  centres  in  the  medulla.  Owing  to  the 
increased  pulmonary  obstruction  a  fronte  and  the  in- 
creased supply  of  blood  a  tergo  (due  to  inspiratory 
suction  movements),  the  right  heart  becomes  gorged 
with  blood  and  eventually  dilated  and  paralysed. 
This  in  turn  leads  to  further  venosity,  which  poisons 
the  myocardium  and  tends  to  further  dilatation,  un- 
til at  length  the  right  auricle  and  ventricle  lose  all 
power  of  contracting.  A  similar  process  also  involves 
the  left  side  ;  but  the  progressive  and  dangerous 
dilatation  of  the  right  side  plays  the  chief  role,  and 
contributes  mainly  to  the  fatal  exitus.2 

A  slowly  progressive  form  of  asphyxia  often  marks 
the  close  of  life,  due  to  a  gradual  impairment  of 

1  Allbutt  and  Rolleston,  vSystem  of  Medicine,  V.,  p.  723. 
2Norris,  Blood-Pressure,  p.   26. 


Itfespiraton?  System  81 


the  respiratory  function.  The  oxygen-content  of 
the  blood  may  fall  to  a  mere  trace,  and  induce  a 
general  narcosis  resulting  in  frequent  and  shallow 
respirations  which  do  but  little  to  aerate  the  blood 
and  gradually  weaken  until  life  ebbs  away. 
In  the  vast  majority  of  cases  the  dying 

"  craving  nought  nor  fearing; 
Drift  on  through  slumber  to  a  dream, 
And  through  a  dream  to  death." 

II.    THE    PLEURA 

Pleurisy.  A  pleuritic  effusion  must,  broadly  speak- 
ing, be  regarded  as  one  of  the  natural  defences  of 
the  organism  in  that  it  lessens  the  risk  of  adhesions 
and  keeps  the  collapsed  lung  quiet.  If  tubercle 
bacilli  happen  to  be  present  their  dissemination  is 
checked.  On  the  other  hand  an  effusion  may  do 
harm  through  interference  with  the  lymphatic 
pump  by  which  a  constant  circulation  of  fluid  into, 
and  out  of,  the  pleuritic  cavity  is  maintained. 
Deposits  of  fibrin  may  block  the  stomata  and  thus 
lead  to  an  accumulation  of  the  effusion.  The 
condition  then  resembles  that  of  a  leaking  ship 
whose  pumps  are  plugged  by  sea-weeds  pouring 
in  with  the  water. 

Further,  the  effusion  may  exert  such  pressure  on 
the  stomata  and  superficial  lymphatics  as  to  block 
the  channels  by  which  it  should  be  absorbed  ;  it 
may  also  make  difficulties  for  itself  by  reducing  or 
abolishing  the  respiratory  movements  on  which  the 
efficiency  of  the  pump  depends.1  The  improvement 
that  so  often  follows  paracentesis,  even  when  only 
a  small  quantity  of  fluid  is  removed,  is  probably  due 
to  an  arrest  of  this  morbid  process.  The  lymphatic 
pump  has  again  begun  to  work  (JMatC  IV.  d). 


1  West,  Lancet,  1905, 1.,  p.  787.    Cf.  also  New  York  Medical 
/.,  1918,  II.,  p.  519. 


82  iDicious  Circles  in  Bieease 


Another  circular  reaction  is  sometimes  associated 
with  an  empyema  when  pus  escapes  into  the  respir- 
atory tract  and  excites  violent  coughing.  Such 
coughing,  on  the  one  hand,  is  an  act  of  self-defence. 
At  the  same  time  the  cough  may  cause  such  a  pro- 
fuse escape  of  pus  as  to  flood  the  respiratory  passages 
and  actually  cause  death. 

After  an  attack  of  pleurisy  the  pleural  membrane 
often  forms  a  locus  minoris  resistentice.  In  spite  of 
recovery  frcm  the  acute  illness  some  residual  lesion 
persists  ;  on  trivial  exposure  the  damaged  pleura  is 
attacked  afresh,  and  each  time  the  mischief  increases, 
until  the  cumulative  effect  is  considerable.  The 
primary  lesion  by  lowering  resistance  has  led  to 
recurrence  ;  recurrence  has  aggravated  the  primary 
lesion. 

Hydro-Thorax.  Many  forms  of  respiratory  and 
cardiac  disease,  especially  in  their  later  stages,  are 
complicated  by  a  general  venous  stasis,  of  which 
dropsy  of  the  pleura  forms  one  condition.  The 
dropsy  in  its  turn  leads  to  further  respiratory  and 
cardiac  embarrassment  and  thus  establishes  a  self- 
perpetuating  condition  which  frequently  gives  the 
coup  de  grace. 

III.     THE    BRONCHI 

Bronchitis.  Circular  reactions  are  frequently 
established  in  acute  bronchitis,  when  the  bronchial 
congestion  obstructs  the  entrance  of  air,  hinders  the 
circulation  through  the  lungs  and  consequently  leads 
to  defective  aeration  of  the  blood.  In  order  to 
overcome  this  obstruction  the  right  ventricle  at 
first  beats  more  vigorously  and  under  favourable 
circumstances  the  circulation  is  satisfactorily  main- 
tained. But  in  severe  attacks  the  heart  frequently 
proves  unequal  to  the  extra  burden  imposed  upon 
it.  The  right  ventricle  and  auricle  undergo  dila- 
tation, and  this  is  followed  by  venous  congestion 


IRespiraton?  System  83 


which  spreads  to  the  venae  azygos,  the  left  superior 
intercostal  and  to  the  bronchial  veins,  thus  further 
aggravating  the  bronchitis. 

Other  injurious  correlations  result  from  congestion 
of  the  coronary  veins,  since  the  nutrition  of  the 
whole  of  the  myocardium  is  thus  involved  and  the 
functional  activity  of  both  ventricles  is  impaired. 
Whether  the  weakness  is  felt  a  tergo  or  a  fronte  the 
bronchial  congestion  is  increased  and  the  bronchitis 
aggravated. 

West  thus  describes  the  process  as  associated  with 
the  left  ventricle  : 

"  As  soon  as  the  left  ventricle  fails,  a  fresh  cause 
of  pulmonary  congestion  is  added,  for  there  can  be  no 
greater  obstruction  to  the  circulation  than  a  left  ven- 
tricle which  cannot  drive  the  blood  onwards.  The 
pulmonary  veins  become  congested,  and  the  aeration 
of  the  blood  is  still  further  interfered  with.  This  adds 
to  the  congestion  of  the  right  side,  embarrasses  still 
more  the  coronary  circulation,  and  by  further  impairing 
the  nutrition  of  the  heart  makes  the  left  ventricle  weaker 
still.  The  Vicious  Circle  thus  established  explains  the 
rapid  failure  of  the  heart,  which  is  so  striking  a  feature 
in  the  later  stage  of  many  cases  of  bronchitis."1 

Similar  complications  arise  in  chronic  bronchitis, 
when  the  compensatory  hypertrophy  of  the  right 
ventricle  fails  and  is  replaced  by  dilatation.  The 
conditions  then  closely  resemble  those  already 
described,  the  bronchial  and  cardiac  disorders  acting 
and  reacting  on  each  other.2 

Chronic  bronchitis  and  emphysema  are  frequently 
reciprocally  related  to  each  other.  Not  only  does 
emphysema  result  from  bronchitis,  but  it  in  turn 
also  leads  to  bronchitis,  for  the  wasting  of  the 

1  Diseases  of  the  Organs  of  Respiration,  I.,  p.  129. 
2Romberg,  Krankheiten  des  Herzens  und  der   Blutgefasse, 
pp.   156-7. 


84  IDicious  Circles  in  2>i0eaec 


alveoli  and  consequent  destruction  of  vessels  causes 
obstruction  to  the  circulation  through  the  lungs. 
This  is  liable  to  be  followed  by  dilatation  of  the 
right  heart  and  systemic  veins,  and  thus  lead  to 
further  congestion  of  the  bronchi. l 

Bronchial  congestion  may  sometimes  be  self- 
perpetuating  owing  to  the  associated  paroxysms 
of  coughing  which  increase  the  congestion.  Pro- 
bably also  the  act  of  coughing  increases  the 
bronchial  secretions  which  in  their  turn  must  be 
removed  by  further  coughing. 

Lastly,  bronchitis  often  supplies  an  example  of  a 
self-perpetuating  disorder  through  the  bronchial 
mucosa  forming  a  locus  minoris  resistentice.  In 
some  persons  each  attack  seems  to  lower  resist- 
ance and  thus  predisposes  to  recurrence. 

Bronchiectasis.  Dilatation  of  the  bronchial  tubes 
occurs  in  a  number  of  disorders,  and  when  once 
it  has  been  started  tends  to  increase  :  dilatation 
breeds  dilatation.  One  reason  for  this  is  that  the 
greater  the  distention  the  less  the  force  required  for 
further  distention,  a  paradoxical  condition  observed 
in  a  variety  of  conditions.2 

Again  in  bronchiectasis  there  is  a  great  tendency 
to  the  accumulation  and  retention  of  secretions. 
This  is  partly  due  to  the  destruction  of  the  ciliated 

1West,  Diseases  of  the  Organs  of  Respiration,  I.,  p.  112. 

2  Such  progressive  dilatation  is  well  illustrated  by  the 
following  experiment.  Suppose  A  and 
B  to  be  two  similar  air  sacs  or  lungs 
attached  to  a  Y-tube  C.,  A  being 
blown  up  to  a  certain  size  and  then 
clamped  at  «,  while  B  is  blown  up  to  a 
larger  size  and  similarly  clamped  at  b. 
If  the  two  clamps  a  and  b  are  removed, 
B  does  not  empty  itself  partially  into  A,  but  A 
partially  empties  itself  into  B  and  grows  smaller. 


•Reepiratorp  S^etem  85 

epithelium,  partly  to  the  increased  calibre  and  less- 
ened elasticity  of  the  tubes.  The  secretions  then 
serve  as  a  nidus  for  bacterial  decomposition,  which 
keeps  up  irritation,  inflammation  and  secretion 
(JMatC  IV.  e).  Gases  too  are  generated  which  exert 
a  dilating  pressure  on  the  enfeebled  walls.1 

Scott  describes  the  process  as  regards  bronchial 
secretions  and  bacterial  growth  : 

"  The  bacteria  present  in  chronic  bronchitis  are 
probably  leading  a  saprophytic  as  well  as  a  parasitic 
existence.  The  organisms  present  are  living  not  only 
on  the  bronchial  epithelium,  but  also  on  the  bronchial 
secretions.  These  secretions  are,  in  the  first  place, 
set  up  by  repeated  bacterial  attacks  on  the  epithelial 
cells,  which  are  then  kept  actively  secreting  by  the 
irritation  of  the  toxins,  a  Vicious  Circle  being  thus 
formed."2 

The  weakening  of  the  bronchial  walls  is  aggra- 
vated b}^  the  frequent  paroxysms  of  cough  which 
result  from  the  accumulated  secretions  ;  these  in 
their  turn  promote  irritation  and  further  secretion. 

Asthma.  Various  hypotheses  have  been  sug- 
gested to  account  for  the  phenomena  associated 
with  paroxysms  of  asthma,  details  of  which  will 
be  found  in  every  System  of  Medicine.  One  re- 
markable feature  of  the  disorder  is  the  defective 
character  of  expiration  which  is  probably  due  to 
the  fact  that  the  expanded  state  of  the  chest 
gives  the  maximum  patency  to  the  bronchial  tree. 
In  other  words  the  patient  dare  not  expire  fully. 

Dixon  and  other  writers,  however,  believe  that 
the  defective  expiration  is  associated  with  a  circulus 
vitiosus  which  operates  through  the  following 
mechanism.  A  much  greater  force  is  exerted  during 
inspiration  than  during  expiration,  which  is  mainly 

1  M.  Bruce,  Principles  of  Treatment,  p.  101. 

2  The  Road  to  a  Healthy  Old  Age,  p.  179. 


86 iptctoug  Circles  in  Btgeaee 

due  to  elastic  recoil  of  the  lungs.  Consequently 
where  there  is  an  asthmatic  broncho-constriction,  air 
may  be  sucked  through  the  constriction  by  the 
inspiratory  force  brought  into  play,  while  the  elastic 
recoil  is  unable  to  expel  the  air  sufficiently  rapidly. 
Another  inspiration  therefore  takes  place  before 
complete  expiration,  resulting  in  over-distention  of 
the  lung.  This  over-distention  in  its  turn  diminishes 
the  force  of  expiration,  i.e.  the  more  the  lungs  are 
distended  the  feebler  becomes  the  power  of  expelling 
air. 

Dixon  writes  : 

a  In  an  attack  of  asthma  due  to  broncho- 
constriction  a  Vicious  Circle  is  established.  The  more 
the  chest  expands  and  the  lungs  are  over-distended 
the  weaker  its  powers  of  expiration  become."1 

Emphysema  and  bronchitis  are  frequent  com- 
plications, being  both  cause  and  effect  of  asthma. 

Iyatham  writes  : 

"  The  amount  of  emphysema,  the  degree  of  bron- 
chial catarrh,  and  the  condition  of  the  right  heart 
are  the  most  important  factors  in  asthma.  These 
complications  all  increase  the  severity  of  the  asth- 
matic attacks,  which  in  turn  increase  the  severity 
of  the  complications,  and  so  the  patient  lives  in  a 
Vicious  Circle."2 

Another  injurious  sequence  may  result  from  the 
gradual  diminution  of  nerve  control,  so  that  a  fresh 
attack  supervenes  on  less  and  less  provocation  ; 
recurrence  indeed  is  largely  the  result  of  previous 
attacks  ( jplatC  IV.  f ).  The  labile  condition  resembles 
that  met  with  in  epilepsy  and  in  various  habit 
spasms. 

lProc.  Royal  S.  of  Med.  (1909),  II.  (iii.),  (Therapeutics] , 
p.  r20.  Cf.  also  Kwart,  British  Med.  J .  (igri),  II., 
p.  1627. 

2  Short,  Index  of  Prognosis,  p.  182. 


Chapter  Siy 


THE   DIGESTIVE   SYSTEM 

ISORDERS  of  digestion  are  usually  com- 
plicated   by    the    operation   of  Vicious 
Circles.    This  liability  arises  in  part  from 
the    interdependence   of    the    chemical, 
physical  and  vital  processes  involved,  in 
part  also  from  the  close  sympathy  between  the  gastro- 
intestinal and  other  organs,  even  the  most  remote. 
Disease  here  breeds  disease  there,  action  and  reaction 
being  in  continuous  operation.     This  complication 
is  largely  accountable  for  the  chronicity  of  dyspeptic 
disorders,  some  of  which  are  most  difficult  to  cure. 
The  following  regional  classification  will  be  con- 
venient : 

I.     The  Mouth 
II.     The  (Esophagus 

III.  The  Stomach 

IV.  The  Liver  and  Pancreas 
V.     The  Intestines 

VI.     The  Rectum  and  Anus 

I.     THE    MOUTH 

Although  every  mouth  is  in  some  degree  septic, 
it  is  not  always  that  injurious  reactions  are  provoked. 
The  establishment  of  Vicious  Circles  depends  on 
the  number  and  pathogenicity  of  the  invaders, 
as  well  as  on  the  resistance  offered  by  the  host. 

Dental  Sepsis.  If  the  teeth  are  not  properly 
cleansed,  particles  of  food,  especially  carbo-hydrates, 
undergo  fermentative  changes,  with  a  production  of 
dextrin  and  of  lactic  and  other  acids  as  end  products. 


88  IDicious  Circles  in  2>ieea0e 

These  acids  attack  the  lime  salts  of  the  enamel 
and  dissolve  the  interprismatic  cement,  as  a  result 
of  which  the  enamel  breaks  up  and  is  removed 
mechanically.  The  solution  of  the  lime  salts  of 
the  dentine  then  follows,  while  the  collagen  of  the 
dentine  matrix  is  dissolved  by  proteolytic  enzymes. 
By  these  processes  cavities  or  pockets  are  formed 
in  which  lodge  food  and  bacteria,  leading  to  further 
fermentation  and  the-  production  of  more  acid 

(IPIate  v.  a). 

The  deposition  of  lime  salts  from  the  saliva  in  the 
form  of  tartar  may  also  establish  morbid  correlations 
by  setting  up  gingivitis  and  causing  recession  of  the 
gums  from  the  tooth,  leaving  the  neck  and  fang 
exposed.  The  exposed  fang  in  its  turn  receives  a 
coating  of  tartar,  which  excites  further  irritation 
and  recession.1  Thus  the  presence  of  dental  cal- 
culus is  self -perpetuating.  In  course  of  time  the  tooth 
loosens  and  drops  out. 

An  artefact  sepsis  is  sometimes  dependent  on 
careless  fillings,  ill-fitting  crowns,  gold  caps  and 
tooth-plates.  These  frequently  lead  to  caries  by 
friction  against  the  teeth,  and  thus  promote  an 
increase  of  the  sepsis  which  rendered  them  necessary.2 

The  teeth,  however,  are  not  merely  isolated 
structures  with  functions  independent  of  those  of 
other  organs  ;  on  the  contrary,  they  have  anatomi- 
cal, physiological  and  pathological  affinities  with 
the  rest  of  the  body.  Hence  it  is  that  dental  sepsis 
may  provoke  such  various  troubles  as  gastro- 
intestinal catarrh,  pneumonia,  infectious  endocardi- 
tis, iritis  or  osteo-myelitis,  and  such  secondary 
disorders  react  on  the  teeth,  cause  and  effect  aiding 
and  abetting  each  other. 

1  Lancet,  1894,1.^.467. 

-British  Med.  /.,  1914,  I.,  pp.  1244,  1301. 


IDujestive  System 


89 


a  I 
i 

\^uou«^<>* 

(a)  DENTAL  CARIES 


(c)  CHOLECYSTITIS 


(b)  QASTROPTOSIS 


a! 


./uaosa^ 

(d)  HERNIA 


(I)  CONSTIPATION 


plate  v.-  Circles  associatcb  with  the 
Bigeettve  System. 


90 iDtdoug  Circles  in  2Hgease 

Coleman  writes  : 

"  Diseased  teeth  or  their  sequelae  such  as  the  con- 
stant swallowing  of  bacteria  and  their  toxins  .... 
may  involve  the  entire  gastro-intestinal  tract  and  its 
annexes,  so  that  Vicious  Circles  become  established 
and  conditions  produced  which  at  first  sight  ma}'  appear 
to  bear  but  little  connection  with  the  teeth.1 

According  to  some  writers  caries  may  hinder  the 
development  of  the  maxillae.  Such  imperfect  de- 
velopment in  its  turn  promotes  caries  and  malnu- 
trition, notably  in  early  life. 

Goadby  writes  : 

"  Among  children  we  find  impaired  nutrition  and 
with  it  impaired  growth  ;  with  this,  again,  badly 
developed  maxillae  and  thus  the  Vicious  Circle  is 
complete."2 

Even  so  common  a  trouble  as  persistent  tooth- 
ache may  provoke  reciprocal  reactions,  when  it 
produces  insomnia,  lowers  the  neuron  threshold  and 
increases  sensitiveness  to  pain.  Here  is  an  illus- 
tration of  the  law  that  attention  and  hypersesthesia 
intensify  each  other. 

Oral  Sepsis.  Dental  sepsis  necessarily  implies 
oral  sepsis.  But  the  converse  does  not  always  hold 
good,  since  the  mouth  may  be  septic  even  when  the 
teeth  are  sound.  The  commonest  oral  disorder  is 
doubtless  pyorrhoea  alveolaris  which  perpetuates 
itself  locally  by  the  formation  of  pockets,  and  also 
produces  similar  constitutional  effects  as  does  dental 
sepsis,  lowers  the  resisting  power  of  the  tissues  and 
thus  facilitates  further  infection  of  the  gums.3 

1St.  Bartholomew's  Hospital  /.,  1909,  II.,  p.  37. 

2 British  Med.  /.,  1904,  II.,  p.  440. 

3vSimilar  injurious  reactions  occur  amongst  the  lower  ani- 
mals with  occasionally  fatal  effects.  British  Med. 
/.,  1914,  L,  p.  1246.  Cf.  also  Colyer,  Chronic 
Periodontitis,  p.  46. 


Digestive  System  91 

Great  attention  has  been  paid  to  these  correlations 
of  recent  years,  and   a  variety  of  disorders  have 
been  attributed  to  them.1 
Payne  writes  : 

"The  chronic  nature  of  the  complaints  associated 
with  the  alimentary  toxaemia  is  largely  due  to  the 
fact  that  a  Vicious  Circle  is  established.  When  once 
oral  sepsis  has  led  to  gastro-intestinal  trouble  the 
oral  sepsis  itself  may  be  kept  alive  by  the  secondary 
complaint."2 

According  to  Pickerill  oral  sepsis  has  much  to  do 
with  weakening  of  the  glosso-pharyngeal-chorda 
tympani-vagus  reflexes  which  govern  salivary  and 
other  secretions,  and  thus  favours  the  proliferation 
of  organisms  and  the  production  of  toxins. 

Pickerill  writes  : 

"  There  is  set  up  an  extremely  strong  Vicious 
Circle.  Diminished  oral  stimulation  produces  oral 
stasis  and  sepsis  initially.  These  in  turn  produce 
gastric  and  intestinal  sepsis,  thus  giving  rise  to  toxins, 
which  being  absorbed  still  further  increase  oral  sepsis 
and  diminish  taste-perception  by  causing  intestinal 
dilatation,  which  increases  toxic  absorption.  And  so 
the  cycle  goes  on  getting  stronger  and  stronger  until 
the  patient's  alimentary  system  can  no  longer  resist 
the  strain  or  perform  its  function.3 

The  conditions  here  described  are  often  met  with 
in  exhausting  illness  when  sordes  accumulate  and 
interfere  with  mastication  and  digestion.  The  same 
is  true  of  aphthous  stomatitis  where  the  taking  of 

xBurchard  and  Inglis,  Dental  Pathology  and  Therapeutics, 
pp.  38,  62. 

2  Lancet,  1913,  II.,  p.  1236  ;   1906,  I.,  p.  509.     Cf.  also  Proc. 

Royal   S.    of     Med.    (1913),    VI.    (i.),    (Alimentary 
Toxcemia),  p.  275. 

3  Dental   Caries   and    Oral  vSepsis,   p.    304.     This  Circle  is 

illustrated  on  p.  299.     Cf.  also  Lancet,  1909,  I.,  p. 
1822. 


92  Melons  Circles  in  Disease 

food  causes  difficulty  and  pain,  and  thus  leads  to 
increased  debility. 

II.    THE   (ESOPHAGUS 

CEsophageal  Pouch.  The  so-called  oesophageal 
pouch  is  a  diverticulum  or  hernia  of  the  posterior 
or  postero-lateral  wall  of  the  pharynx  into  the 
adjacent  loose  areolar  tissues.  As  food  enters  and 
distends  the  sac,  the  oesophagus  below  is  apt  to  be 
compressed,  causing  more  food  to  enter  the  sac 
and  increasing  its  size.  Moreover  the  pouch,  as  it 
grows,  may  come  to  form  the  direct  continuation 
of  the  pharynx,  and  this  again  causes  more  food 
to  enter.  As  a  result  of  this  retention  of  food, 
decomposition  is  liable  to  occur,  and  this  leads 
to  inflammation,  spasm  and  increased  retention. 

Starck  writes  : 

"  In  the  treatment  of  dilatation  of  the  oesophagus  the 
most  important  thing  to  bear  in  mind  is  the  prevention 
of  inflammation,  as  when  this  occurs  a  Vicious  Circle 
is  established.  Inflammation  is  followed  by  spasm, 
spasm  by  obstruction,  and  obstruction  by  further 
inflammation."1 

Unless  the  diverticulum  can  be  cured,  death  may 
result  from  slow  starvation. 

(Esophagismus.  Spasmodic  stricture  or  oesopha- 
gismus  is  not  uncommon  in  neurasthenic  individuals 
and  may  be  of  purely  psychical  origin.  The  more 
the  victim  fears  the  advent  of  the  spasm  the  more 
likely  is  its  advent,  and  vice  versa.  The  condition 
illustrates  the  spasmophilia  which  characterises 
the  emotional  temperament. 

1  Die  Divertikel  und  Dilatationen  der  Speiserohre,  abstracted 
in  British  Med.  /.,  1911,  II.,  p.  1599.  An  excellent 
diagram  of  an  oesophageal  pouch  is  given  by  Schmidt, 
Krankheiten  der  oberen  I^uftwegen,  p.  726. 


Digestive  S^atem  93 


III.     THE   STOMACH 

Reciprocity  of  disorder  in  connection  with  the 
stomach  is  of  frequent  occurrence.  A  few  striking 
examples  may  be  referred  to.1 

Chronic  Gastritis.  The  various  gastric  functions 
involved  in  digestion  are  so  intimately  associated 
that  impairment  of  the  one  involves  the  others. 
Deficiency  of  secretion  spells  deficiency  of  absorp- 
tion and  of  peristalsis,  and  vice  versa.  It  matters 
little  which  function  suffers  first  ;  when  the  chain 
is  dragged  the  links  must  follow.  In  Allbutt's 
words  :  "  the  stomach  falls  into  the  Vicious  Circle 
of  doing  as  ill  for  itself  as  for  other  parts  of  the 
body."2 

Ewald  describes  the  sequence  : 

"  Defective  muscular  movement  reacts  by  diminish- 
ing the  activity  of  absorption,  defective  absorption 
leads  to  stasis  in  the  venous  area,  and  this  again  to 


JThe  term  Vicious  Circle  has  sometimes  been  applied 
to  disorders  in  which  there  are  no  reciprocal 
processes  in  operation,  and  which,  therefore,  do  not 
fall  under  the  definition  given  in  the  Introduction. 
Such  a  disorder  is  occasionally  established  after 
a  gastro-enterostomy,  when  the  gastric  contents  pass 
through  the  anastomosis  and  return  to  the  stomach 
through  the  duodenum,  or  else  pass  first  into  the 
duodenum  and  return  to  the  stomach  through  the 
anastomosis. 

Trendelenburg  also  describes  a  "  Vicious  venous 
Circle,"  which  may  complicate  varicose  veins  of  the 
leg  where  the  valves  are  incompetent.  After  passing 
through  the  saphena  vein  into  the  veins  which  connect 
the  superficial  with  the  deep  veins,  the  blood  flows  into 
the  popliteal  and  femoral  veins  back  into  the  saphena 
vein,  thus  flowing'from,  instead  of  towards,  the  heart 
and  completing  the  circuit.  Da  Costa,  Modern 
Surgery,  p.  409. 

2Allbutt  and  Rolleston,  System  of  Medicine,  III.,  p.  388. 


94  IDicious  Circles  in  Disease 

injury  to  secretion,  so  that  a  Vicious  Circle  is  created. 
You  can  easily  perceive  that  it  is  quite  the  same  at 
whichever  end  you  begin  this  chain  ;  whether  the 
first  trouble  is  secretory  or  motor,  or  absorption  is 
affected,  the  same  results  must  always  follow,  unless 
the  failure  of  the  one  function  can  be  compensated  for 
by  the  stronger  action  of  another,  by  which  the  dis- 
turbance might  be  rectified."1 

Chronic  gastritis  is  usually  associated  with  some 
degree  of  gastrectasis,  especially  when  there  has 
been  prolonged  retention  of  food.  Such  retention 
leads  to  decomposition  and  fermentation,  as  a  result 
of  which  enormous  quantities  of  gas  may  be  gen- 
erated, with  the  result  that  the  stomach  yields  more 
and  more  to  the  pressure.  The  retention  and 
dilatation  thus  aid  and  abet  each  other.2  Such 
gastrectasis  is  frequently  associated  with  stenosis 
of  the  pylorus  due  to  cancer.3 

In  many  cases  the  gastrectasis  seems  to  excite 
boulimia  which  then  further  increases  the  gastric 
dilatation. 

M.  Bruce  writes  : 

"  The  subjects  of  chronic  gastric  catarrh,  associated 
with  a  degree  of  dilatation  of  the  stomach  from  atony 
of  the  wall  develop  an  excessive  appetite  and  eat 
largely.  A  Vicious  Circle  is  established,  and  the  morbid 
condition  aggravates  itself  automatically."4 

Acute  gastrectasis  associated  with  paralysis  of 
the  walls  and  retention  of  gases  and  secretions  is 

Diseases  of  the  Digestive  Organs,  II.,  p.  484.  Cf.  also 
Cohnheim,  General  Pathology,  III.,  p.  857  ;  Rosen- 
heim,  Krankheiten  der  Speiserohre  und  des  Magens, 
p.  96. 

2 Cohnheim,  General  Pathology,  III.,  pp.  859,  862.  Cf. 
also  British  Med.  /.,  1902,  II.,  pp.  1390,  1393. 

3Vierordt,  Medical  Diagnosis,  p.  345. 

4  Principles  of  Treatment,  pp.  471,  458-9. 


Digestive  System  95 

sometimes  seen  in  severe  illness  and  is  an  indication 
of  great  danger.  Here  also  the  several  factors 
intensify  each  other.1 

Gastroptosis.  Some  degree  of  gastroptosis  is 
invariably  associated  with  gastrectasis,  owing  to  the 
prolonged  retention  and  increased  weight  of  the 
ingest  a.  But  the  displacement  becomes  aggravated 
when  the  loaded  stomach  sinks  so  low  as  to  produce 
a  duodenal  kink,  since  such  kink  further  hinders 
the  escape  of  the  gastric  contents.2  The  gastroptosis 
and  gastrectasis  then  intensify  each  other,  and 
the  stomach  may  assume  enormous  dimensions.3 
The  mechanical  displacement  aggravates  the  dis- 
order to  which  it  was  due  ({plate  V.  b). 

In  some  cases  the  distended  stomach  forces  down 
the  intestines  in  such  a  way  that  the  mesenteric 
blood-vessels  and  nerves  form  a  tight  band  across 
the  duodenum  and  prevent  any  gas  from  passing. 
The  tighter  the  band  the  greater  the  accumulation 
of  gas  and  vice  versa. 

Barnard  describes  the  process  : 

"  In  some  cases  of  acute  paralytic  dilatation  of  the 
stomach  it  would  appear  that  the  small  intestines  have 
been  driven  downwards  and  backwards  into  the  pelvis 
by  the  enlarging  organ,  and  that  the  mesentery  has  been 
drawn  tightly  across  the  duodenum.  In  such  cases,  in 
addition  to  the  stomach,  the  duodenum  is  distended  to 
the  point  at  which  it  is  crossed  by  the  mesentery,  and  a 
Vicious  Circle  is  thus  established."4 

1  Krehl,  Basis  of  Symptoms,  p.  253.     Cf.  also  Keen,  Surgery, 

III.,  p.  949. 

2  Billings,  Diseases  of  the  Digestive  System,  p.  271.     Cf. 

also  British  Med.  /.,   1902,  II.,  p.   1397  ;    Lancet, 
rgir,  II.,  p.  215. 

3  Such  a  stomach  may  contain  as  much  as  seventy  pints. 

4Allbutt  and  Rolleston,  System  of  Medicine,  III.,  p.  769. 


96 iDicious  Circles  in  Disease 

A  curious  complication  may  occur  owing  to  the 
fact  that  any  imbibed  liquid  does  not  reach  the 
intestines,  and  consequently  can  neither  be  absorbed 
nor  quench  thirst.  Hence  the  unallayed  thirst 
causes  more  drinking,  producing  increased  distention 
of  the  stomach,  increased  obstruction,  and  increased 
difficulty  in  satisfying  thirst.  Thus  a  paradoxical 
condition  may  arise  in  which  a  person  is  tormented 
with  thirst,  although  his  stomach  contains  several 
pints  of  fluid.1 

Hyperchlorhydria.    A  circular  reaction  is  some- 
times   present    in     hyperchlorhydria,    a    condition 
which  is  present  in  various  forms  of  dyspepsia. 
Thus  Sippy  writes  : 

"  In  true  hyperchlorhydria  a  Vicious  Circle  is 
established.  Excessive  gastric  secretion  is  excited  by 
the  presence  of  food.  The  excessive  acidity  irritates 
the  nerves  of  the  gastric  niucosa  and  the  glands  respond 
to  the  normal  stimulus,  food,  by  pouring  out  excessive 
secretion,  which  renders  the  gastric  mucosa  irritable."2 

This  disorder,  however,  is  much  more  serious 
when  it  is  complicated  and  aggravated  by  the 
presence  of  pyloric  spasm. 

During  normal  digestion  the  pyloric  sphincter 
remains  for  the  most  part  closed,  relaxing  at  intervals 
to  allow  the  passage  of  acid  chyme,  and  then  closing 
again  under  the  influence  of  the  duodenal  reflex. 
In  cases  of  hyperchlorhydria,  however,  this  mechan- 
ism is  liable  to  be  disturbed.  The  usual  alternation 
between  opening  and  contraction  of  the  sphincter  is 
then  replaced  by  persistent  spasm,  followed  by 
retention  of  the  gastric  contents.  Such  retention 
then  provokes  further  hyperchlorhydria  and  com- 

^irchow,  Archiv,  CLVI.  (1899),  p.  306. 

2Musser  and  Kelly,  Practical  Treatment,  III.,  p.  367.     Cf. 

also  von  Noorden,  Zeitschrift  /.  klin,  Medizin  (1904) 

UIL,  p.  7. 


Digestive  System  97 

pletes  the  round.  In  fact  hyperchlorhydria,  pyloric 
spasm  and  gastric  stasis  may  form  an  obstinate 
concatenation  of  disorders.1 

Mathieu  and  Roux  write  : 

"Reichmann's  syndrome  presents  a  remarkable 
example  of  a  pathogenic  Vicious  Circle.  The  following 
are  the  component  factors  :  persistent  pain,  hyper- 
secretion  of  gastric  juice,  hyperchlorhydria  and  stasis. 
The  spasm  of  the  pylorus  has  been  proved  to  be  the 
principle  cause  of  the  pain  and  gastric  stasis.  The 
stasis  in  its  turn  perpetuates  the  hyper-secretion,  and 
this  again  perpetuates  the  spasm.  In  a  considerable 
number  of  cases  there  is  an  ulcer  at,  or  near,  the  pylorus 
which  causes  the  pain,  spasm  and  hyper-secretion. 
In  fact  the  hyper-secretion  and  stasis  prevent  the 
healing  of  the  ulcer."2 

Gastric  Ulcer.  The  sequence  of  hyperchlorhy- 
dria, spasm  and  stasis  referred  to  above  is  met 
with  in  many  cases  of  gastric  ulcer.  Ulcers  may 
also  occur  apart  from  any  such  spasm,  in  which 
case  the  hyperchlorhydria  and  ulceration  perpetuate 
each  other.  Doubtless  the  presence  or  absence  of 
spasm  depends  on  the  degree  of  acidity,  on  the 
situation  of  the  ulcer  and  on  the  state  of  the  nervous 
system. 

Roux  describes  the  morbid  sequence  : 

"  The  hyperchlorhydria  which  is  so  constantly  pres- 
ent in  cases  of  gastric  ulcer,  may  be  due  to  reflex 
irritation.  On  the  other  hand  clinical  observations 
seem  to  indicate  ....  that  in  many  cases  the  hyper- 
chlorhydria precedes  the  ulcer.  We  may  therefore 
conclude]  that  the  hyperchlorhydria  promotes  the 
formation  of  the  ulcer,  while,  on  the  other  hand,  by 

1  Pyloric   spasm   may    also   perpetuate   a   state   of   hyper- 

chlorhydria   by    preventing    any  reflux  of  alkaline 
pancreatic  juice.     Lancet,  1915,  I.,  p.  290. 

2  Pathologic  Gastro-Intestinale,  Series  I.  (1909),  p.  149.    Cf. 

also  Practitioner,  1915,  I.,  p.  240. 


98  IDtdcws  Clrclee  in  SMseasc 

means  of  a  Vicious  Circle,  the  ulcer  once  formed 
increases  the  hyper-secretion  and  the  hyperchlorhydria. 
This  concatenation  of  phenomena  may  well  explain 
the  tendency  of  the  ulcer  to  become  chronic."1 

The  adhesions  which  so  frequently  form  round 
the  base  of  the  ulcer  are  doubtless  a  provision  of 
Nature  to  prevent  perforation,  or  to  localise  the 
subsequent  peritonitis,  should  the  ulcer  give  way. 
Such  adhesions,  however,  are  by  no  means  an  un- 
mixed blessing,  since  they  cause  fixation  of  the 
ulcer,  prevent  its  undergoing  the  contraction  which 
is  so  necessary  for  repair,  and  thus  delay  recovery. 

Acute  Gastritis.  Acute  gastritis  is  sometimes 
brought  on  through  dietetic  indiscretion,  as  for 
instance  when  unwholesome  or  excessive  food  has 
been  taken.  The  result  may  be  acute  inflammation 
which  checks  digestion,  and  is  followed  by  severe 
flatulence  and  fermentation  which  perpetuate  the 
gastritis. 

Ewald  describes  the  sequence  : 

"  The  impaired  secretion  and  peristalsis  give  rise  to 
inflammation  of  the  mucosa,  which  in  its  turn  further 
checks  the  gastric  secretion  and  thus  establishes  a 
Vicious  Circle  in  optima  forma.  Putrefactive  and 
fermentative  decomposition  supervenes  as  an  aggra- 
vating factor."2 

Aerophagy.  The  habit  of  aerophagy  or  wind- 
swallowing  as  met  with  in  neuropaths  may  be  a 
self -perpetuating  disorder.  In  some  cases  the  eruct- 
ations consist  of  gas  which  has  never  passed  beyond 
the  oesophagus  ;  usually  they  are  brought  up  from 
the  stomach.  The  habit  probably  begins  with  an 

1  Debove,  Achard  and  Castaigne,  Maladies  du  Tube  Digestif, 

I.,  p.  205. 
2Eulenburg,  Real-Encyclopadie  der  gesammten  Heilkunde 

XIV.,  p.  258. 


Digestive  System  99 


attack  of  flatulence  which  the  sufferer  discovers  he 
can  relieve  by  voluntary  belching.  The  forced 
belching,  however,  while  of  some  benefit,  really 
aggravates  the  discomfort,  and  produces  the  sensa- 
tion of  an  object  lying  just  behind  the  larynx. 
He  therefore  belches  again  and  the  habit  may 
thus  be  indefinitely  repeated.  Indeed  some  persons 
are  occupied  all  day  long  in  rhythmic  air  gulping 
and  eructation  so  as  to  be  scarcely  fit  for  decent 
society.  More  air  may  be  swallowed  than  is  expelled 
by  eructation  so  that  the  stomach  grows  more  and 
more  distended.1 

Mathieu  and  Roux  describe  the  process  : 

"  Severe  aerophagy  generally  shews  itself  in  neuro- 
paths, and  results  from  their  predisposition  and  nervous 
temperament.  Moreover  in  its  turn  it  aggravates  the 
neurasthenia  or  one  or  other  symptoms  of  that  disorder 
by  means  of  one  of  those  Vicious  Circles  that  are  so 
common  in  neuropathology.  Many  of  the  sufferers 
are  inclined  to  worry  about  trifles  or  are  subject  to 
definite  phobias.  They  dread  the  approach  of  an 
attack  of  aerophagy,  and  that  is  precisely  what  is 
likely  to  provoke  a  recurrence.  Thus  they  tend  to 
grow  more  and  more  neurasthenic."2 

Other  gastric  disorders  associated  with  neuroses 
are  dealt  with  in  chapter  three. 

Parasitic  Infection.  Perversion  of  the  appetite 
is  sometimes  produced,  particularly  in  children,  by 
the  presence  of  the  ascaris  lumbricoides  or  one  of 
the  species  of  ankylostoma  duodenale,  the  perverted 
appetite  taking  the  form  of  pica  or  geophagy. 
Earth  or  even  faeces  may  be  eaten,  and  as  the  ova 

1  Air  gulping  occurs  frequently  in  horses  and  cattle  and  may 
result  in  fatal  wind-colic.  The  stomach  may  be  so 
distended  as  to  produce  total  obstruction.  Wyllie, 
Edinburgh  Hospital  Reports  (1895),  III.,  p.  21. 

2 Pathologic  Gastro-Intestinale,  Series  I.  (1909),  p.  r85. 


ioo          Oicious  Circles  in  S)i0ea0e 


are  excessively  common  in  the  soil  this  indulgence 
often  increases  the  infection.  In  other  words  the 
infection  excites  the  earth  hunger  and  this  perpetu- 
ates the  infection. 

Geophagy  is  very  common  in  Egypt  and  other 
countries  where  embryos  and  ova  swarm  in  the 
soil.  A  single  female  ascaris  is  said  to  discharge 
60,000,000  ova. 

Another  self-perpetuating  process  may  be  con- 
nected with  the  presence  of  the  tsenia  solium  in  the 
small  intestines  when  the  parasite  sets  up  anti- 
peristalsis.  Through  this  mechanism  larvae  may  be 
returned  to  the  stomach  where  the  acid  juice  dis- 
solves the  larval  case  and  allows  the  parasite  to 
regain  the  intestines.  Thus  a  form  of  auto-infection 
may  take  place. 

The  same  sequence  may  occur  in  the  life-history 
of  the  hymenolepsis  nana,  another  tape-worm  that 
is  prevalent  in  Italy. 

IV.  THE  IvIVER  AND  PANCREAvS 
The  liver  is  closely  associated  with  the  other 
digestive  organs  both  in  health  and  disease.  In  its 
various  disorders  there  is  frequently  a  mutuality  of 
cause  and  effect  whose  influence  we  have  now  to 
study. 

Congestion.  There  is  some  degree  of  hepatic 
derangement  in  almost  all  forms  of  dyspepsia.  In 
slight  attacks  such  as  those  included  under  the 
term  biliousness  the  disorder  is  functional  and 
rapidly  subsides. 

In  severe  attacks  there  may  be  actual  congestion 
resulting  from,  as  well  as  aggravating,  the  disordered 
gastric  and  intestinal  condition. 

Lauder  Brunton  thus  describes  the  sequence  of 
events  : 

"  Indiscretion  in  eating  or  drinking  disturbs    the 
digestive   processes   in   the   stomach    and    intestines  ; 


Digestive  System  101 

the  products  of  imperfect  digestion  or  of  decomposition 
in  the  intestine  being  absorbed  into  the  veins  pass  to  the 
liver  ;  they  may  there  induce  an  obstructed  flow 
through  the  hepatic  capillaries  ;  the  venous  blood 
returning  from  the  stomach  and  intestines  will  no 
longer  be  able  to  find  an  easy  passage  into  the  general 
circulation,  and  venous  congestion  of  the  stomach  and 
intestines  will  be  the  result.  Such  venous  engorge- 
ment as  this  will  interfere  with  gastric  and  intestinal 
digestion,  and  this  again  will  react  upon  the  liver. 
Here,  then,  is  a  Vicious  Circle  which  it  is  necessary  to 
break."1 

Congestion  of  the  liver  may  also  be  associated 
with  heart  disease  and  in  turn  aggravate  such 
disease.  In  the  early  stages  of  heart  failure  the 
liver  may,  owing  to  the  interdependence  of  the  two 
organs,  give  some  relief  to  the  heart  by  allowing 
some  of  the  blood  that  would  have  overtaxed  the 
cardiac  chambers  to  accumulate  in  the  capacious 
hepatic  blood-vessels.  But  the  hepatic  functions 
and  those  of  the  portal  viscera  generally  are  apt, 
in  their  turn,  to  become  deranged,  and  as  a 
further  consequence  the  cardiac  failure  is  increased. 
Indeed  death  may  occur  as  a  result  of  a  process 
which  originally  benefited  the  heart.  Here  is  a 
good  example  of  an  organic  Circle  in  which  two 
interdependent  organs  injuriously  affect  each  other. 

M.  Bruce  thus  describes  the  later  stages  of  such 
failure  : 

"  The  da}7  of  reckoning  has  come.  Bad  has  led  to 
worse.  A  Vicious  Circle  is  established  :  the  penalty 
attending  the  accommodating  process  and  the  vicarious 
action  by  which  one  organ  relieves  another  organ  in 
distress.  This  result  appears  at  first  sight  to  be  at 
variance  with  the  self-adjusting,  self-righting  properties 
of  the  body.  Instead  of  spontaneously  recovering,  one 
diseased  organ  is  found  upsetting  other  organs  to  its 

1  Disorders  of  Digestion,  p.  25. 


102 IDtdoug  (Ttrclee  in  SHseaee 

own  further  detriment,  if  for  its  own  temporary  relief. 
This  must  apparently  be  accepted  as  a  primary  or 
essential  physiological  necessity  in  connection  with  all 
complex  organisations  and  structures.  In  physiology, 
just  as  in  finance,  mutual  accommodation  is  invaluable 
and  indeed  indispensable,  and  it  is  often  permanently 
as  well  as  temporarily  successful  inasmuch  as  it  affords 
time  and  opportunity  for  recovery  of  position.  But 
the  relation  on  which  the  employment  of  it  depends, 
namely,  the  mutual  dependence  of  associated  interests, 
is  liable  to  land  us  in  widespread  and  hopeless  ruin. 
In  a  word,  Vicious  Circles  are  one  of  the  penalties  that 
have  to  be  paid  for  the  many  advantages  of  organisa- 
tion. The  number  and  area  of  the  Vicious  Circles  set 
up  by  disease  are  practically  unlimited.  The  instances 
just  given  are  striking  examples,  but  a  similar  order 
of  widening  and  deepening  disturbances  may  be  traced 
into  all  the  great  systems  in  disease  of  any  moment  : 
arrest  of  digestion,  alimentation  and  elimination  ; 
disorder  of  sleep  ;  interference  with  exercise  and  its 
attendant  benefits,  and  so  on."1 

Biliary  Calculus.  The  processes  concerned  in 
lithiasis  are  well  illustrated  by  the  formation  of  a 
biliary  calculus,  where  the  setiological  factors  include 
the  stagnation  of  bile,  bacterial  infection  and  catarrh 
of  the  biliary  passages.  A  nucleus  of  cholesterol  is 
deposited,  round  which  collect  epithelial  cells  and 
bilirubin  calcium.  Such  a  nucleus,  even  though 
small,  acts  somewhat  like  a  foreign  body,  causing 
irritation  and  desquamation  of  the  mucosa,  the 
products  of  which  adhere  to,  and  increase  the  size 
of,  the  nucleus.  From  increasing  size  result  in- 
gravescent irritation  and  catarrh,  and  so  the 
process  is  accelerated  (jplatC  V.  c). 

MacCallum  describes  the  sequence  : 

"  All   gall-stones   contain   a  great   deal   of   organic 
material  derived  from  desquamated  epithelial  cells  and 

1  Principles  of  Treatment,  p.  189. 


Digestive  System  103 

coagulated  albuminous  matter  as  well  as  pigment. 
Many  of  them  contain  bacteria,  and  are  formed  in 
infected  bile  and  within  a  gall-bladder  which  is  in- 
flamed, because  in  this  Vicious  Circle  the  presence  of 
the  stone  aids  in  giving  a  foot-hold  to  bacteria,  while 
they  in  turn,  through  the  inflammation  they  set  up, 
aid  in  the  growth  of  the  stone."1 

In  some  cases  of  cholelithiasis  the  calculus  blocks 
the  outlet  of  the  gall-bladder  like  a  ball- valve. 
Hence  results  an  accumulation  of  bile,  and  the 
greater  the  accumulation  the  more  tightly  is  the 
outlet  plugged. 

Cholecystitis  may  also  be  self-perpetuating  when 
the  inflammation  of  the  mucosa  extends  to  the 
cystic  duct  and  narrows  its  lumen.  Such  narrowing 
is  then  apt  to  lead  to  retention  and  putrefaction  of 
bile,  followed  by  increased  narrowing,  and  so  the 
process  continues  until  obstruction  is  complete. 

Infective  catarrh  of  the  bile-ducts  appears  at 
times  to  excite  a  similar  condition  of  the  pancreatic 
ducts  which  then  in  turn  reacts  on  the  bile-ducts. 

Musser  and  Kelly  write  : 

"  Infective  cholangitis  constitutes  a  Vicious  Circle 
with  chronic  pancreatitis.  The  infection  from  the 
biliary  tract  involves  the  pancreas  which  in  turn 
becomes  swollen  and  indurated  and  creates  more  or 
less  obstruction  to  the  passage  of  bile  down  the  common 
bile  duct,  which  in  two-thirds  of  all  cases  runs  for  a 
short  distance  through  the  head  of  the  pancreas  before 
piercing  the  posterior  wall  of  the  duodenum.  As  a 
result  of  this  obstruction  the  infective  phenomena  in 
the  biliary  duct  are  furthered  and  each  condition 
become  mutually  disadvantageous  to  the  other."2 

Pancreatic  calculi  and  retention  cysts  develop  in 

1  Text-Book    of    Pathology,    p.    392.      Cf.    also    Rolleston, 

Diseases  of  the  Liver,  p.  606. 
-Practical  Treatment,  IV.,  p.  697. 


104         \Dictou0  Circles  In  S>l0ea0e 

much  the  same  way  as  do  similar  conditions  in  the 
liver. 

Hepatic  Insufficiency.  In  certain  diseases  such 
as  acute  yellow  atrophy  the  hepatic  functions  may  be 
gravely  upset  by  toxic  agents  which  endanger  the 
structure  of  the  hepatic  cells.  These  cells  may  even 
undergo  a  process  of  self-digestion  or  autolysis 
resulting  in  the  suppression  of  all  the  hepatic,  especi- 
ally of  the  antitoxic,  functions.  The  result  is  a 
cumulative  increase  of  the  toxic  or  cholsemic  con- 
dition. The  toxaemia  and  arrested  antitoxic  activi- 
ties aggravate  each  other  and  a  fatal  issue  is  not 
infrequent. 

Monod  writes  : 

"  By  hepatism  we  mean  a  diathesis,  hereditary  or 
acquired,  characterised  by  inadequacy  of  the  liver  cells. 
A  Vicious  Circle  is  thus  created,  the  toxins  set  free 
reacting  in  turn  on  the  cells  of  the  liver.  Disturbance 
of  the  intra-hepatic  circulation  follows,  and,  in  sequence 
to  this,  there  arises  a  like  disturbance  of  circulation  in 
the  bowel."1 

Wells  has  drawn  attention  to  the  reciprocal  effect 

on  each  other  of  cholsemia  and  biliary  obstruction- 

"  Since  bile  salts  cause  haemolysis,  and  since  in  even 

haematogenous  jaundice  they  enter  the  blood,  it  can 

readily  be  seen  that  in  this  way  an  increased  formation 

of  bile-pigment  may  be  incited  which  leads  to  further 

obstruction  to  the  outflow  of  bile  from  the  liver,  and 

a  Vicious  Circle  may  thus  be  established."2 

This  sequence  of  events,  however,  by  no  means 
always  occurs. 3 

One  form  of  cholaemia  (acholuric  jaundice)  is 
caused  by  rapid  blood  destruction.  This  is  fol- 

lProc.  Royal  5.  of  Med.  (1913),  VI.  (i.),  (Alimentary  Tox- 

<zmia),  pp.  180,  267. 
2  Chemical  Pathology,  p.  445. 
3Parkes  Weber,  Practitioner,  1916,  II.,  p.  145. 


H>tge0ti\>e  System  105 


lowed  by  polycythsemia  and  this  in  its  turn  by 
further  blood  destruction.1  The  condition  resem- 
bles that  described  under  polycythaemia  (p.  65). 

According  to  various  writers  eclampsia  may  at 
any  rate  be  partly  dependent  on  hepatic  insufficiency. 
Probably  there  is  reciprocation  of  cause  and  effect 
between  hepatic  and  renal  insufficiency,  not  only 
in  eclampsia  but  in  various  toxic  conditions.  The 
condition  has  already  been  referred  to  on  p.  68 2 

Other  hepatic  and  renal  correlations  may  be 
established  when  excess  of  uric  acid  in  the  blood 
has  been  caused  by  inadequacy  of  hepatic  metabolism 
and  is  associated  with  calculous  nephritis.  For 
example,  the  liver  under  certain  conditions  fails  to 
produce  sufficient  uricolytic  enzyme  to  transform  all 
the  uric  acid  reaching  it  into  urea.  Consequently 
the  excess  of  uric  acid  passes  on  to  the  kidney, 
where  some  of  the  acid  may  form  calculous  deposits 
in  the  renal  pyramids,  and  give  rise  to  a  secondary 
chronic  nephritis.  The  result  will  be  a  lessened 
internal  renal  secretion,  and  this  in  turn  causes 
lessened  uricolytic  enzyme  in  the  liver. 

Hepatoptosis.  Ptosis  of  the  liver  is  closely 
associated  with  general  visceroptosis,  the  symptoms 
of  the  latter  largely  obscuring  those  of  the  minor 
displacement.  Under  normal  conditions  the  visceral 
surface  of  the  liver  rests  on  a  shelf  formed  mainly 
of  the  right  kidney,  colon,  stomach  and  the  first 
section  of  the  duodenum  and  pancreas,  this  shelf 
being  held  in  place  by  the  abdominal  muscles.  The 
posterior  portion  of  the  liver  is  attached  to  the 
diaphragm  by  the  meso-hepar,  consisting  of  blood- 
vessels, connective  tissue  and  peritoneum. 

1Ward,  Bedside  Haeraatology,  pp.  157,  220. 
?Wells,  Chemical  Pathology,   p.  487.     Cf.  also    Osier  and 
Macrae,  System  of  Medicine,  III.,  899. 


io6         iDtcioug  Circles  in  ^Disease 

Under  various  circumstances,  however,  the  abdo- 
minal walls  become  greatly  stretched  and  weakened, 
with  the  effect  that  the  support  usually  given  to  the 
shelf  is  lost.  The  liver  consequently  tends  to  rotate 
on  the  meso-hepar  and  to  fall  downwards  and  back- 
wards. The  greater  the  relaxation  of  the  abdominal 
walls  the  greater  the  tendency  to  hepatoptosis  and 
vice  versa.  The  sequence  may  also  originate  in 
excessive  constriction  of  the  thorax  by  the  corset 
which  dislocates  the  liver.  Displacement  of  the 
liver  in  its  turn  involves  some  degree  of  interference 
both  with  the  circulation  of  blood  and  of  bile,  and 
such  interference  must  tend  to  increase  the  weight 
of  the  organ.1  All  the  factors  are  aggravated  by 
the  almost  invariably  associated  general  viscero- 
ptosis. 

The  increased  weight,  stretched  ligaments  and 
disordered  functions  of  a  displaced  liver  are  apt, 
as  in  the  case  of  other  displaced  organs,  to  give  rise 
to  vague  aches  and  pains,  which,  especially  in 
neurotic  persons,  keep  the  attention  constantly 
fixed  on  the  displacement.  Thus  there  is  a  con- 
stant repercussion  between  exaggerated  sensitiveness, 
emotivity  and  consciousness  which  frequently  ends 
in  chronic  invalidism.  "  A  Vicious  Circle  is  apt  to 
be  established  owing  to  the  inherent  state  of 
emotivity  of  the  neurasthenic."2 

V.    THE    INTESTINES 

Some  of  the  circular  reactions  alluded  to  in  con- 
nection with  the  stomach  reappear  mutatis  mutandis 
in  connection  with  the  intestines.  But  a  number  of 


1  Experimental  evidence  of  Biliary  Obstruction  in  Floating 
I/iver  is  given  by  Steele,  University  of  Pennsylvania 
Med.  Bulletin  (1902),  XV.,  p.  424 

2Mott,  Lancet,  1918,  L,  p.  128.  Cf.  also  Norris,  Blood- 
Pressure,  p.  180. 


Digestive  System  107 

fresh  examples  result  from  the  peculiar  anatomical 
relations  of  the  latter. 

One  of  the  chief  requirements  for  the  health  of  an 
organism  is  that  its  conduits  be  free  from  obstruction. 
Everywhere  does  obstruction  cause  disorder,  which 
varies  from  temporary  discomfort  to  grave  disease 
or  even  death.1  The  healthy  organism  possesses 
numerous  mechanisms  for  the  removal  of  such 
obstruction,  such  as  vomiting,  increased  peristalsis 
and  abdominal  straining,  and  in  minor  degrees  of 
disorder  these  mechanisms  prove  highly  efficient. 
They  are,  however,  of  limited  potency  ;  they 
often  fail  of  their  purpose,  and  it  is  a  remark- 
able fact  that  such  failure  usually  aggravates  the 
primary  disorder.  Obstruction  may  be  due  to 
defective  propulsive  power,  to  narrowed  conduits  or 
to  inspissation  of  solid  or  liquid  matters  in  transit  ; 
numerous  examples  of  these  conditions  occur  in  con- 
nection with  the  digestive  tract. 

Spasm.  Excess  of  peristalsis  sometimes  takes 
the  form  of  spasm  due  to  irritation  of  the  intestinal 
walls.  The  irritation  produces  spasm  and  the  spasm 
in  turn  keeps  up  the  irritation.  Mansell  Moullin 
thus  describes  the  process  as  met  with  in  cases  of 
duodenal  ulcer  : 

"All  that  the  pain  really  indicates  is  that  there  is  an 
irritable  hyper-responsive  condition  of  the  mucous 
membrane  so  that  a  stimulus  which  in  ordinary  cir- 
cumstances would  produce  only  a  normal  result,  calls 
into  play  a  reaction  which  is  not  only  excessive  in 
amount,  but  which  persists  and  continues  so  long  as 
the  condition  is  present.  If  this  goes  on,  if  the  spasm 
and  contraction  are  kept  up,  it  ends  in  the  establish- 
ment of  a  typical  Vicious  Circle,  the  increased  respons- 


further  details  cf.  Obstruction  and  its  Vicious  Circles, 
by  J.B.H.,  Clinical  /.,  1915,  I.,  p.  145. 


io8         iDictoue  Circles  tn  Bieeaee 

iveness  of  the  mucous  membrane  intensifying  the 
muscular  spasm,  and  the  increased  muscular  spasm 
irritating  the  mucous  membrane  still  more  by  crushing 
the  tender  surfaces  together.  It  is  the  formation  of 
this  Vicious  Circle  that  holds  the  secret  not  only  of  the 
symptoms  that  are  present  in  what  is  commonly  known 
as  duodenal  ulcer,  but  of  the  reason  why  they  are 
relieved  with  such  certainty  and  success  by  the  oper- 
ation of  gastro-enterostomy  when  all  else  has  failed."1 

The  colon  is  another  frequent  seat  of  spasm, 
especially  when  coprostasis  has  caused  irritation  of 
the  mucous  membrane.  Coprostasis  may  be  both 
cause  and  effect  of  spasm  : 

Mathieu  and  Roux  write  : 

"  Not  only  does  the  spasm  cause  and  keep  up  the 
constipation,  but  the  constipation  in  its  turn  keeps  up 
the  spasm  and  the  colitis." 

And  again  : 

"  Under  the  influence  of  spasm  faecal  matters  are 
retained  in  the  intestine,  which  is  thus  kept  in  a  state 
of  constant  irritation.  This  irritation  then  provokes 
painful  manifestations  and  various  reflexes,  some  of 
short,  some  of  long  circuit.  Those  of  short  circuit  are 
confined  to  the  intestinal  walls,  while  the  longer  ones 
take  a  further  route  and  involve  the  abdominal  plexuses. 
These  spasmogenic  reflexes  in  their  turn  perpetuate  the 
constipation  and  the  intestinal  irritation.  Thus  is 
formed  a  Vicious  Circle,  which,  when  once  established, 
shows  no  tendency  to  disappear  spontaneously."2 

Displacement.  The  intestines  are  liable  to  vari- 
ous forms  of  displacement  which  may  be  a  self- 

1  Lancet,   1912,  I.,  pp.  564,  566.     Cf.   also  Schryver  and 

Singer,  Quarterly  J.  of  Med.,  VI.,  pp.  331,  337. 

2  Pathologic  Gastro-Intestinale,  Series  I.   (1909),  pp.   149, 

442,  448  ;   Series  III.  (1911),  pp.  93,  303.     Cf.  also 
Schmidt,  Klinik  der  Darmkrankheiten,  p.  328. 


Digestive  $£6tem  109 

aggravating  condition.  A  striking  example  occurs 
when  the  transverse  colon  descends  into  the  pelvis 
forming  an  M-shaped  loop.  The  longer  the  loop 
the  greater  the  tendency  to  the  accumulation  of 
faeces,  while  the  accumulated  faeces  favour  further 
elongation  and  descent.  In  connection  with  such 
visceroptosis  adhesions  are  apt  to  form  at  the  various 
intestinal  flexures,  causing  permanent  kinking  of  the 
gut  and  aggravation  of  the  stasis,  as  Arbuthnot 
I/ane  has  so  frequently  pointed  out. 

Hernia  presents  another  common  example  of 
displacement.  Every  time  the  gut  descends  the 
ring  tends  to  enlarge,  which  enlargement  facilitates 
a  redescent  of  the  gut.  Further,  a  strangulated 
hernia  frequently  provokes  vomiting  and  vomiting 
increases  the  strangulation  (JMate  V.  d). 

Inflammation.  Enteritis  may  also  be  self-per- 
petuating. The  inflammatory  condition  leads  to 
impaired  peristalsis  and  this  is  followed  by  stasis, 
increased  bacterial  growth  and  further  inflammation . 

E.  von  Ofenheim  writes  : 

"  The  question  as  to  the  effect  of  stasis  on  bacteria 
and  of  bacteria  on  stasis  is  interesting,  for  a  Vicious 
Circle  has  repeatedly  been  proved  to  exist  between 
them.  Stasis  causes  bacterial  poisons  to  be  formed; 
these  poisons  again  have  a  paralysing  effect  on  the 
intestines,  and  in  this  way  add  to  the  stasis."1 

The  appendix  is  probably  the  commonest  seat  of 
enteritis.  Here  the  inflammatory  process  is  apt  to 
cause  some  obstruction  of  the  duct  with  a  second- 
ary retention  of  secretions.  Such  retention  in  its 
turn  aggravates  congestion  and  obstruction  of 
the  duct.  Progressive  accumulation  and  congestion 
then  result,  until  a  completely  closed  cystic  cavity 

lProc.  Royal  S.of  Med.  (1913),  VI.  (i.),  (Alimentary  Toxa- 
mia),  p.  326. 


no          iDicious  Circles  in  Disease 

is  formed.1  The  retained  matters  also  excite  in- 
flammation of  the  muscular  walls  and  diminish 
peristalsis,  thus  promoting  further  retention  (flMftte 
V.  e). 

Similar  correlations  may  be  associated  with  chronic 
appendicitis  leading  to  fibrosis. 

Battle  and  Corner  write  : 

"  Fibrosis  of  the  appendix  interferes  with  the  com- 
pleteness of  its  peristaltic  action,  and  as  a  result  the 
tube  will  become  incapable  of  emptying  itself.  By 
these  means  a  Vicious  Circle  is  established  in  that  more 
pabulum  remains  within  for  the  bacteria  to  flourish 
upon,  and  the  more  bacteria  flourish,  the  more  likely 
it  is  that  chronic  inflammation  will  progress,  and  the 
organ  become  still  more  incapable  of  performing  its 
own  evacuation.  Such  a  condition  may  be  called 
appendicular  constipation.  The  inspissation  of  the 
contents  will  lead  to  the  formation  of  an  appendicular 
calculus  or  fsecal  concretion,  which  may  be  likened  to 
scybala  elsewhere  in  the  large  intestine."2 

The  caecum  is  another  region  of  the  intestine 
which  is  very  liable  to  inflammation,  giving  rise  to 
typhlitis.  At  times  the  mischief  may  be  due  to  the 
escape  into  the  caecum  of  toxic  matters  from  the 
appendix  : 

Battle  and  Corner  write  : 

"  The  Vicious  Circle  results  from  the  fact  that  the 
inflammatory  condition  will  impair  the  contractile 
power  of  the  caecum,  and  so  lead  to  further  bacterial 
growth  and  further  chronic  inflammation.  In  this 
way  a  colitis  may  be  established  throughout  the  whole 
length  of  the  large  bowel." 

aThe  process  here  described  applies  to  many  of  the  ducts 
of  the  body,  e.g.  the  pancreatic  duct,  the  bile  duct, 
the  salivary  duct  and  intestinal  diverticula. 

2  Surgery  of  the  Diseases  of  the  Vermiform  Appendix, 
pp.  30,  38.  Cf.  also  Stewart,  Practitioner,  1910,  I., 
p.  790. 


£\>etem 


And  again  : 

"  Owing  to  the  pause  of  the  products  of  digestion  in 
the  caecum,  ....  the  fermentative  processes  initiated 
in  the  appendix  will  proceed  to  further  stages  in  the 
caecum.  As  a  result  a  secondary  subacute  or  chronic 
typhlitis  is  started  which  leads  to  interference  with  the 
muscular  action  of  the  caecum  and  further  retention  of 
the  contained  fermenting  faecal  mass.  In  this  way  a 
Vicious  Circle  has  been  started,  and  the  processes  and 
their  results  may  extend  along  the  colon  from  segment 
to  segment."1 

Residents  in  the  tropics  are  liable  to  a  special 
form  of  chronic  inflammation  of  the  alimentary 
tract  known  as  sprue  or  psilosis  which  is  compli- 
cated by  what  Manson  calls  a  "  Vicious  pathological 
Circle."  The  dominant  factors  are  dyspepsia  leading 
to  malassimilation,  with  tissue  starvation  and  de- 
struction. As  a  result  of  this  lesion  of  the  mucosa 
digestion  and  absorption  are  interfered  with  and 
result  in  further  malnutrition  which  frequently 
terminates  fatally.2 

Obstruction.  Mechanical  obstruction  has  already 
been  alluded  to  in  connection  with  several  disorders. 
But  the  same  complication  occurs  in  a  variety  of 
circumstances,  as  for  example  through  simple  inspis- 
sation  of  the  faeces  caused  by  unusual  absorption 
of  the  liquid  constituent.  Moreover  hardened  faeces 
may  give  rise  to  faecal  concretions  which  enlarge 
by  further  deposits,  much  as  do  biliary  or  vesical 
calculi. 

Mummery  writes  : 

"  The  longer  faecal  material  is  delayed  in  its  passage 
along  the  colon,  the  harder  will  it  become,  owing  to  the 
absorption  of  water  by  the  bowel  walls  :  and  the 

^xirgery    of   the    Diseases   of   the   Vermiform    Appendix, 

pp.  30,  70. 
2Allbutt  and  Rolleston,  System  of  Medicine,  II.  (ii.),  pp. 

550,  557- 


iDicious  Circles  tn  Disease 


harder  it  becomes  the  less  easily  will  it  be  driven  on  by 
peristalsis,  so  that  a  Vicious  Circle  is  soon  established."1 

In  many  conditions  of  stasis  some  degree  of  hypo- 
thyroidism  may  be  brought  about  through  the 
absorption  of  bacterial  toxins  .  Such  hypothyroidism 
in  its  turn  weakens  nervous  and  muscular  activity 
which  is  followed  by  further  stasis. 
McCarrison  writes  : 

"  The  stasis  once  established  may  lead  to  subthy- 
roidism  by  the  action  on  the  gland  of  the  toxic  products 
of  bacterial  growth  in  the  static  bowel,  or  the  abnormal 
processes  of  digestion  may  interfere  with  the  efficient 
elaboration  of  the  thyroid's  secretion,  thus  reducing 
its  physiological  activity.  A  Vicious  Circle  is  thereby 
established  which  in  either  event  augments  the  thyroid 
defect  as  well  as  the  stasis."2 

Again  faecal  stasis  is  often  associated  with  a  great 
accumulation  of  gas  which  impairs  the  contractile 
powers  of  the  muscular  walls,  and  this  impairment 
leads  to  further  accumulation.  The  distention  also 
perpetuates  itself  by  diminishing  the  absorption  of 
gases  by  the  blood-vessels. 
Nothnagel  writes  : 

"  As  soon  as  the  amount  of  gas  present  exceeds  a 
certain  limit,  the  intestine  becomes  distended,  and  this 
inhibits  the  absorption  of  gas  by  the  blood-vessels  of 
the  intestinal  wall.  In  addition  the  excessive  distention 
impairs  the  contractile  powers  of  the  intestinal  mus- 
culature. All  three  factors  in  their  turn  lead  to  the 
further  accumulation  of  gas  in  the  intestine.  In  this 
way  a  Vicious  Circle  which  cannot  be  interrupted 
results,  and  causes  the  colossal  meteorism  occasionally 
seen  in  stenosis  of  the  intestine."3 

1  Diseases  of  the  Colon,  p.  219. 

2  The  Thyroid  Gland,  pp.  138,  187.     Cf.  also  Practitioner, 

1915,  I.,  p.  66. 

3  Diseases  of  the  Intestines  and  Peritoneum,  pp.  140,  638. 

Cf,  also  Mummery,  Diseases  of  the  Colon,  p.  35. 


Digestive  System  113 

Another  form  of  obstruction  is  due  to  intussuscep- 
tion, when  the  intestine  is  telescoped  on  itself  and 
the  intussusceptum  excites  active  peristalsis  in  the 
intussuscipiens.  The  peristalsis  in  turn  increases 
the  length  of  the  invaginated  intussusceptum,  cause 
and  effect  acting  and  reacting  reciprocally  on  each 
other. 

Ascites.  Attention  has  already  been  directed  to 
the  self-perpetuating  character  of  effusion  into  the 
pericardial  and  pleural  sacs.  Peritoneal  effusions 
may  be  similarily  complicated.  When  they  are 
caused  by  heart  failure  they  may  in  their  turn 
aggravate  such  failure  and  thus  cause  grave  peril 
to  life.  Again  ascitic  effusion,  by  pressure  on  the 
renal  veins,  may  impede  the  excretion  of  urine  ; 
the  impeded  excretion  further  increases  the  ascites. 

VI.    THE    RECTUM    AND    ANUS. 

Constipation.  The  most  important  process  of 
reciprocation  falling  under  this  heading  is  that 
associated  with  habitual  constipation,  which  is  one 
of  the  commonest  ills  of  civilized  life.  The  dis- 
order may  be  congenital  or  acquired,  local  or  consti- 
tutional, physical  or  psychical,  trivial  or  fatal.  No 
age,  no  sex,  no  occupation,  no  race,  no  country  is 
immune.  In  brief,  the  disorder  is  of  well-nigh  uni- 
versal interest,  particularly  to  the  physician,  the 
sociologist,  the  psychologist,  the  teacher.1 

Some  forms  of  constipation  have  already  been 
alluded  to  in  the  previous  section  ;  others  are  as- 
sociated with  the  rectum  and  the  anus.  In  the 
first  place  must  be  mentioned  the  habitual  disregard 
of  the  natural  call,  such  disregard  being  followed  by 
a  progressive  blunting  of  the  associated  reflex  and 
by  increased  constipation. 

1  For  further  details  cf .  Vicious  Circles  of  Habitual  Constipa- 
tion, by  J.B.H.,  Practitioner,  1915,  II.,  p.  560. 


H4         Melons  Circles  in 


Again  faeces,  when  unduly  retained  in  the  rectum, 
lose  much  of  their  contained  liquid  by  absorption, 
and  form  dry  and  hard  scybala.  Their  expulsion  is 
difficult  and  the  difficulty  favours  retention. 

Faecal  stasis  in  the  rectum,  when  persistently 
neglected,  is  apt  to  produce  atony  and  dilatation  of 
the  rectum,  conditions  which  aggravate  the  primary 
stasis.  The  dilatation  thus  induced  may  affect  the 
whole  circumference  of  the  bowel  ;  in  other  cases 
the  rectum  becomes  the  seat  of  local  pouching, 
more  especially  in  old  age.  The  pouching  both 
results  from  and  causes  constipation. 

Nascher  describes  the  process  : 

"  The  weakening  and  waste  of  muscle  fibres,  whereby 
peristaltic  activity  is  diminished,  is  frequently  accom- 
panied by  neglect  of  the  aged  to  attend  the  call  of 
evacuation  of  the  bowel,  and  this  last  is  the  main 
cause  of  the  dilatation  of  the  colon  and  rectum,  whereby 
pouches  are  formed.  Here  we  see  one  of  the  many 
Vicious  Circles  which  are  found  in  old  age.  The  dimin- 
ished elasticity  of  muscle  permits  dilatation  of  the  gut, 
which  consequently  becomes  rilled  with  fecal  matter 
distending  the  bowel,  this  distension  further  stretching 
the  fibres  and  impairing  their  elasticity."1 

A  similar  condition  may  lead  to  the  formation  of  a 
rectocele,  such  as  is  common  in  women.  As  the 
faeces  collect  in  the  sac  caused  by  the  bulging  rectal 
wall,  great  straining  at  stool  is  required  to  expel 
the  faeces.  This  straining  increases  the  size  of  the 
pouch,  leading  to  further  lodgment  and  increased 
straining. 

Dyschezia  is  another  cause  of  habitual  constipa- 
tion since  it  inhibits  peristalsis  and  postpones  expul- 
sive efforts.  Such  constipation  may  again  increase 
the  lesion  which  caused  the  pain. 

1  Geriatrics,  p.  34. 


2>f<je0tiv>e  System  115 

Robin  and  Dalche  refer  to  some  forms  of  dyschezia, 
which  are  met  with  in  women  : 

"  A  uterine  displacement,  a  peri-uterine  phlegmasia, 
a  hsematocele,  a  salpingitis,  a  fibroid,  etc.,  may  act 
mechanically  and  give  rise  to  constipation,  which  is 
followed  by  quite  a  number  of  dyspeptic  symptoms. 
...  On  the  other  hand,  constipation  may  itself  do 
harm  to  a  healthy  uterus,  and  by  means  of  a  Vicious 
Circle  may  aggravate  the  uterine  disorders  to  which  it 
was  primarily  due."1 

Iii  neurasthenic  persons  the  ovary,  even  when 
healthy,  may  become  tender  and  cause  pain  when 
scybala  pass  over  it.  Such  pain  may  then  tempt  a 
woman  to  postpone  defalcation,  with  the  result 
that  her  scybala  get  harder  and  cause  more  pain 

(BMate  v.  f). 

Spasm  of  the  sphincter  due  to  haemorrhoids  or 
fissure  is  another  cause  of  constipation  which  in 
its  turn  perpetuates  those  disorders. 
Ball  writes  : 

"  As  a  result  of  the  constant  motion  and  distention 
and  by  the  lodgment  of  particles  of  fseces  in  the  rent, 
continued  irritation  is  set  up,  which  in  turn  occasions 
spasm  of  the  sphincter.  The  spasm  once  started,  the 
irritation  is  increased,  and  so  a  Vicious  Circle  is  estab- 
lished, and  the  result  is  that  the  ulcer  is  never  allowed 
to  heal."2 

Prolapsus  Ani.  There  is  frequently  a  mutuality 
of  cause  and  effect  in  the  case  of  prolapsus  recti. 
Prolapse  causes  tenesmus  and  tenesmus  increases 
prolapse.  Prolapse  also  causes  relaxation  of  the 
sphincter  ;  such  relaxation  favours  prolapse. 

^raitement   Medical    des   Maladies   des   Femmes,    p.    18. 
Cf.    also  Schmidt,  Klinik  der  Darmkrankheiten,  p. 

443- 

-The  Rectum  and  Anus,  p.  131.     Cf.  also  Treves,  System 
of  Surgery,  II.,  p.  754. 


n6         tPickms  Circles  in  S)tgea0e 

Edwards  writes  : 

"  The  more  the  bowel  comes  down,  the  more  is  the 
sphincter  stretched  and  relaxed,  and  the  increasing 
atony  favours  the  repetition  of  the  prolapse."1 

Strangulation  of  Piles.     Prolapsed  piles  some- 
times become  strangulated  and  cause  such  irritation 
as  to  provoke  spasm  of  the  sphincter.     The  spasm 
increases  the  strangulation. 
Spriggs  writes  : 

"  It  is  important  to  remember  that  whilst  chronic 
constipation  may  cause  piles,  tender  piles  will,  by 
making  constipation  painful,  cause  constipation."2 

Oxyurides.  A  circular  reaction  may  occur  in 
persons  whose  rectum  is  infested  with  oxyurides. 
The  itching  and  scratching  at  the  anus  lead  to  the 
helminths  or  their  ova  being  caught  under  the 
nails,  conveyed  to  the  mouth  or  food,  and  swallowed 
by  the  host.  From  the  stomach  the  ova  reach  the 
intestines  and  rapidly  attain  maturity.  Thus  the 
irritation  ensures  by  auto-infection  successive  gener- 
ations of  the  parasite.  Fertile  ova  are  frequently 
discoverable  under  the  finger-nails  of  the  oxyuris 
host,  and  Cabot  believes  that  fresh  infection  is  an 
almost  daily  or  nightly  occurrence.3  Possibly  there 
may  also  be  infection  by  an  ascending  current 
during  the  act  of  vomiting.4 

Pruritus  Ani.  This  forms  a  very  troublesome 
neurosis  especially  in  predisposed  persons.  The 
pruritus  leads  to  scratching  and  the  scratching 
intensifies  the  itching. 

As  Treves  says  : 

"  The  itching  is  so  intense  that  it  is  impossible  to 

1  Diseases  of  the  Rectum,  Anus  and  Sigmoid  Colon,  p.  367. 

2  Practitioner,  1910,  I.,  p.  628. 

3  Modern  Clinical  Medicine,  p.  551. 

4Debove,  Achard  and  Castaigne,  Maladies  du  Tube  Digestif, 
II.,  pp.  306,  327. 


S>tge0ti\>e  System  117 

avoid  scratching,  which,  instead  of  giving  relief,  only 
adds  to  the  trouble."1 

This  process  of  self-aggravation,  however,  is  only 
temporary.  A  sense  of  satisfaction  is  also  yielded  by 
scratching  and  may  culminate  in  a  form  of  orgasm 
which  ends  in  a  state  of  depression  and  relief. 

The  above  regional  description  of  injurious  circular 
reactions  may  be  concluded  by  a  brief  survey  of  the 
nervous,  muscular  or  chemical  mechanisms  connect- 
ing the  various  portions  of  the  digestive  tract  with 
one  another  and  with  other  great  systems  of  the 
body. 

The  functional  activities  of  the  mouth,  stomach, 
intestines,  liver  and  pancreas  are  all  linked  together 
by  reciprocally  acting  correlations,  so  that  if  one 
organ  suffers  all  the  others  are  more  or  less  sympa- 
thetically affected.  If  unsuitable  or  badly-cooked 
food  enters  the  stomach  it  may  set  up  fermentation 
with  the  production  of  lactic  and  butyric  acids, 
which  irritate  the  gastric  mucosa,  provoke  catarrh 
and  cause  an  unhealthy  secretion  of  mucus,  which 
further  hinders  digestion.  Moreover  the  excessive 
evolution  of  gases  weakens  peristalsis  and  this  in 
turn  induces  stasis  and  more  fermentation.  Doubt- 
less the  formation  of  the  gastric  hormone  is  also 
checked. 

As  a  result  of  these  disorders  the  intestines,  liver 
and  pancreas  are  subjected  to  abnormal  reflex  stimuli 
which  disturb  their  physiological  activities.  The 
ingesta,  as  they  reach  the  duodenum,  are  unprepared 
for  intestinal  digestion  and  absorption,  and  irritate 
the  mucosa.  The  alkaline  juices  are  unable  to 
neutralise  the  normal  acid  secretions  of  the  stomach 
when  these  are  combined  with  lactic  and  butyric 
acid,  so  that  the  reaction  of  the  food  in  the  intestines 

1  System   of  Surgery,   II.,   p.    793.      Cf.  also    Hirschman, 
Diseases  of  the  Rectum,  p.  105. 


n8          IDictoug  Circles  in  Disease  _ 

continues  acid  instead  of  alkaline,  and  this  results 
in  irritation  and  disturbance  of  the  processes  of 
secretion.  Bile  is  retained  in  the  liver,  instead  of 
being  poured  into  the  intestine,  and  suffers  in 
composition  owing  to  the  reflex  irritation  of  the 
liver  caused  by  the  disorders  in  the  stomach  and 
intestines.  The  liver  loses  the  power  of  arresting  and 
destroying  many  of  the  toxins  that  reach  it  during 
the  processes  of  digestion.  These  toxins  therefore 
continue  in  the  circulation  and  disturb  the  normal 
control  of  the  nervous  system  over  digestion. 

Further,  owing  to  the  loss  of  the  antiseptic  powers 
of  bile,  the  pancreatic  juice  mixed  with  food  rapidly 
undergoes  decomposition,  with  the  production  of 
poisons  such  as  skatol,  indol  and  a  variety  of  poison- 
ous alkaloids.  These  in  their  turn  are  absorbed  and 
react  injuriously  on  the  processes  of  digestion. 
Doubtless  also  the  production  of  secretin  is  dimin- 
ished with  injurious  reverberation.  Thus  cause 
and  effect  react  ceaselessly  on  each  other  and 
explain  the  chronicity  of  many  digestive  troubles. 

But  not  only  are  there  reciprocal  correlations 
between  the  various  digestive  organs.  There  is 
also  the  closest  synergy  and  sympathy  between 
the  digestive  and  all  other  systems,  percussion  and 
repercussion  extending  to  the  most  intimate  pro- 
cesses. Thus  it  is  a  matter  of  every  day  experience 
that  the  psychical  state  and  digestive  functions  are 
inter-dependent.  Disturbance  of  either  may  grie- 
vously upset  the  other.  As  Hippocrates  long  ago 
laid  down  in  his  famous  aphorism  : 

<ocrirep    Totcrt    SeVSpetriz/    rj    yfj,   ovrat    rouri 
£woiru>  17  yacrT^/o,  "  What  the  soil  is  to  the  tree 
that  the  stomach  is  to  the  animal."1 


//•     Cf.   also  The  Story  of  the  Belly  and 
the  Members,  as  told  by  Shakespeare,  Coriolanus,  I. 
101. 


2>i$e0tive  system  119 

It  is  on  this  relation  of  the  digestion  to  the 
animal  that  many  disorders  depend.  If  digestion  is 
out  of  order,  the  animal  suffers.  If  the  animal  is 
out  of  health  its  digestion  suffers  ;  here  is  involved 
the  problem  of  nutrition  in  all  its  ramifications. 

The  sensitive  tissues  of  the  nervous  system  might 
on  a  priori  grounds  be  expected  to  suffer  early 
where  the  sources  of  nutrition  are  curtailed  through 
defective  digestion,  and  such  is  found  to  be  the  fact. 
Impaired  digestion  quickly  disturbs  the  nerve  centres, 
and  ill  nourished  nerve  centres  soon  react  on  the 
digestive  processes,  these  organs  reciprocally  embar- 
rassing each  other.  Worse  still,  if,  in  consequence 
of  retention  and  decomposition  of  food,  poisons 
are  brewed  and  the  blood  which  should  nourish 
the  nerve  tissues  is  itself  tainted.  No  wonder  that 
under  such  conditions  morbid  interactions  are  set 
up  which  reverberate  in  many  directions.  Such 
interactions  may  be  caused  by  disorder  in  any  part 
of  the  digestive  tract  from  the  mouth  to  the  anus. 
Everywhere  may  toxic  conditions  arise  which  injure 
the  nervous  tissues.  Pyorrhoea,  gastrectasis,  copro- 
stasis  are  but  a  few  illustrations  of  daily  occurrence. 

Other  reciprocal  correlations  exist  between  the 
digestive  organs  and  the  heart.  For  example,  low- 
ered vitality  resulting  from  chronic  gastritis  may 
lead  to  an  irregular  and  weak  cardiac  action,  which 
further  interferes  with  digestion.  Even  an  accumu- 
lation of  flatulence  may  be  a  source  of  cardiac  distress 
which  reacts  on  equanimity  and  consequently  on 
digestion.  This  is  especially  common  where  the 
heart  is  already  unsound. 

Robin  writes  : 

"  Gastric  disorders  are  very  apt  to  disturb  the  action 
of  a  healthy  heart.  All  the  more  readily  will  they  affect 
a  diseased  organ,  even  though  the  latter  originally 
caused  the  dyspepsia. 

This  Vicious  Circle,  as  a  result  of  which  the  diseased 


120         IPtctoug  Circles  in  Disease 

heart  gives  rise  to  gastric  disorders  which  in  turn 
react  on  the  heart,  is  exceedingly  common,  and  many 
errors  of  diagnosis  will  be  avoided  if  this  fact  is  borne 
in  mind."1 

The  respiratory  functions  may  also  be  depreciated 
by  disorders  of  digestion,  the  effect  being  especially 
injurious  in  children. 

Arbuthnot  Lane  writes  : 

"  The  diminution  in  respiratory  capacity  which  is 
brought  about  by  indigestion  in  young  people,  is  a 
matter  of  vital  importance,  and  is  a  very  material 
factor  in  lowering  the  activity  of  all  the  vital  pro- 
cesses in  the  body.  In  the  first  instance  deficient 
aeration  and  oxygenation  result  from  serious  alter- 
ations in  the  abdominal  mechanics.  Later  a  Vicious 
Circle  is  formed,  the  deficient  aeration  impairing 
digestion  processes."2 

These  few  illustrations  must  suffice  to  indicate 
some  of  the  inter-dependences  existing  between  the 
digestive  and  other  systems  of  the  body.  The  list, 
however,  is  far  from  exhausted  ;  for  disorders  of 
digestion  are  so  closely  associated  with  other  dis- 
orders of  the  body  that  disturbance  of  the  equili- 
brium existing  between  them  radiates  far  and  wide, 
cause  and  effect  reacting  continuously  on  each  other. 

The  study  of  these  correlations  throws  fresh  light 
on  another  aphorism  of  Hippocrates  : 

'ZvfJiTTa.ffea  TTOLVTO.'  KOTO,  [j.€i>  ovXo/xeAup  TrdvTa, 
Kara  /A  epos  Se  ra  eV  e/caorw  /ae/>et  pepta  TTOO? 
TO  epyov.  "  The  whole  body  sympathises  with 
every  member,  and  every  member  with  the 
whole  body  throughout  its  structure."3 


JI,es  Maladies  de  1'Estomac,  p.  966. 

2  Operative  Treatment  of  Chronic  Constipation,  p.  16. 

« llepl  Tpo<f>rj<s,  §  23.     Cf.  also  I.  Corinthians,  XII.,  26. 


Chapter  Seven 


THE    URINARY   SYSTEM 

ISORDERS  of  the  urinary  apparatus  pre- 
sent illustrations  of  organic,  mechanical, 
neurotic  and  chemical  forms  of  Vicious 
Circles,  some  of  which  possess  consider- 
able clinical  importance. 

We  shall  deal  in  order  with  : 
I.     The  Kidneys 
II.     The  Ureters 

III.  The  Bladder  and  Prostate 

IV.  The  Urethra 

THE    KIDNEYS 

The  kidneys  are  the  chief  emunctories  of  the 
body  and  excrete  large  quantities  of  toxic  and  effete 
substances  that  result  from  physiological  processes. 
The  healthier  the  kidneys  the  greater  their  excretory- 
efficiency  ;  the  greater  that  efficiency  the  healthier 
the  kidneys  will  remain.  In  disease  an  excess  of 
toxic  materials  of  abnormal  virulence  is  formed 
and  thrown  on  to  the  kidneys  for  excretion,  and 
such  an  increase  of  waste  products  within  limits 
tends  to  increase  the  eliminating  activity  of  the 
kidneys  ;  by  means  of  this  mechanism  many  dis- 
eases are  self -limiting.1 

1 A  large  number  of  diseases  are  self -limiting  until  a  Vicious 
Circle  supervenes  and  interferes  with  natura  medi- 
catrix.  Striking  illustrations  of  such  interference 
occur  in  nephritis,  bronchitis,  pleurisy,  apoplexy, 
cardiac  failure,  tuberculosis  etc. 
121 


iDictous  Circles  in  ^Disease 


It  frequently  happens,  however,  that  such  toxic 
and  waste  products  tax  the  kidneys  beyond  their 
capacity,  as  a  result  of  which  they  are  retained 
in  the  blood  where  they  further  depreciate  renal 
efficiency,  and  so  the  process  is  perpetuated. 

Nephritis.  Such  a  mutuality  of  cause  and 
effect  is  met  with  in  various  forms  of  nephritis. 
Toxins  in  the  blood  may  produce  nephritis  and 
such  nephritis  keeps  the  blood  toxic  (JMatC  VI.  a). 
Retention  toxaemia  is  added  to  the  primary  toxaemia. 
There  may  be  slight  renal  impairment  or  total 
anuria  according  to  the  virulence  of  the  poison. 
Cf.  also  p.  68. 

Adami  writes  : 

"  Functional  inadequacy  of  the  kidneys  is  not  with- 
out its  effect  upon  the  composition  of  the  blood.  The 
quantity  of  water  eliminated  may  deviate  considerably 
from  the  normal,  and  waste  products  may  be  retained 
instead  of  excreted.  The  quality  of  the  blood  is  thus 
depreciated,  and,  being  laden  with  toxic  substances, 
it  in  turn  exerts  an  irritating  and  deteriorating  effect 
upon  the  kidneys.  In  this  way  a  Vicious  Circle  is  set  up, 
as  a  result  of  which  the  condition  of  the  patient  goes 
rapidly  from  bad  to  worse."1 

Destructive  changes  in  the  renal  epithelium  appear 
in  some  cases  to  cause  a  product  of  the  internal 
secretion  from  the  kidneys  (renin)  to  be  cast  into 
the  circulation  and  in  its  turn  to  further  damage  the 
renal  tissues. 

ChaufTard  and  Ivaederich  write  : 

"  There  can  be  no  doubt  that  certain  alterations  in 
the  renal  cells  may  give  rise  to  toxic  matters,  which  in 
their  turn  perpetuate  these  alterations  and  create  a 

1  Principles  of  Pathology,  II.,  p.  735. 


TBrinan>  System 


123 


(a)  NEPHRITIS 


(c)  CYSTITIS 

X^j 

-  t 

\\      /' 

^V^xlt, 


(e)  OVER-DISTENTION  OF 
BLADDER 


f 

I 


o 

\S-X/ 

S/SOJV^ 
(b)  NEPHROPTOSIS 


(d)  PROSTATIC  RETENTION 


(f)  URETHRAL  STRICTURE 


plate  VI.— Circles  a00ociatet>  witb  the 
Iflrinari?  Spetem, 


124          IDicious  Circles  in  Disease 

true  Vicious  Circle,  the  effect  of  which  is  a  more  or  less 
indefinite  continuance  of  the  nephritis.1 

The  swelling  of  the  kidneys  associated  with  many 
forms  of  nephritis  is  apt  to  interfere  mechanically 
with  the  circulation  and  thus  becomes  a  self-aggrava- 
ting condition.  Total  anuria  may  result  and  call 
for  incision  of  the  cortex. 
Fischer  writes  : 

"  Vicious  Circles  are  established  in  many  organs 
when  once  the)7  begin  to  swell.  The  swelling  com- 
presses their  blood  supply  and  thus  aggravates  their 
already  precarious  state.  Dehydration  of  the  kidney 
by  the  salt  restriction  scheme  of  therapy  may  suffice 
to  save  it."2 

After  an  attack  of  inflammation  the  kidneys  are 
frequently  prone  to  recurrence  of  the  disease  on 
slight  provocation.  Each  fresh  attack  seems  to 
injure  fresh  areas  so  that  the  disease,  on  each  occasion, 
advances  a  step  further.  Increased  susceptibility 
and  recurrence  act  and  react  on  each  other,  the 
kidneys  becoming  a  locus  minoris  resistentice. 

According  to  Hare  a  circular  reaction  is  often 
present  in  renal  cirrhosis  as  a  result  of  the  associated 
vaso-constriction.  This  vaso-constriction  leads  to 
increased  diuresis,  thirst,  increased  ingestion  of 
water  and  further  diuresis.  The  increased  amount 
of  urine  is  the  result  of  the  circulatory  changes 
instituted  by  the  organism  to  maintain  the  ordinary 
rate  of  excretion. 

Hare  writes  : 

"  There  is  on  this  view  a  distinctly  appreciable  and 
highly  Vicious  Circle  in  operation.  The  Circle  comprises 

^rouardel   et  Gilbert,   Maladies  des  Reins,   p.    166.     Cf. 

also    Kolmer,    Infection,    Immunity    and    Specific 

Therapy,  p.  505. 
2  (Edema  and  Nephritis,  pp.  30,  613. 


1&rinan>  System  125 

continuous  vaso-constriction  :  deficiency  of  water  in 
the  tissues  :  thirst  :  increased  ingestion  of  water  ;  and 
increased  diuresis.  The  water  drunk  does  not  ade- 
quately relieve  the  thirst,  since  it  fails,  on  account  of 
the  peripheral  vaso-constriction,  to  flush  adequately 
the  tissues  and  thus  to  remove  the  essential  cause  of 
the  thirst  :  in  other  words,  the  water  drunk  is  largely 
short-circuited  through  the  kidneys."1 

Nephritis  may  also  perpetuate  itself  when  com- 
plicated by  ascites,  since  the  ascites  interferes  with 
the  secretion  of  urine  by  pressure  on  the  renal 
veins  or  on  the  ureters.  Such  interference  in  turn 
increases  the  ascites. 

Romberg  writes  : 

"  Ascites  may  obstruct  the  escape  of  blood  through 
the  renal  veins,  and  by  thus  retarding  the  circulation 
through  the  kidneys  may  diminish  diuresis.  An  im- 
portant circulus  vitiosus  may  be  established  in  this 
way,  unless  the  oedema  and  transudations  can  be  got 
rid  of."2 

Again  some  forms  of  ascites  excite  thirst,  the 
gratification  of  which  may  increase  the  dropsy.  In 
the  words  of  Horace  :  "  Crescit  indulgens  sibi  dirus 
hy  drops."3 

Movable  Kidney.  In  neurasthenic  persons, 
especially  women,  chronic  ill-health  may  be  associ- 
ated with  a  movable  kidney.  The  over-sensitive 
nervous  system  renders  the  sufferer  unduly  conscious 
of  the  abnormal  mobility,  while  tbe  persistent  ache 
renders  the  nervous  system  more  and  more  sensitive. 


'Food  Factor  in  Disease,  II.,  p.  332. 
-  Krankheiten  des  Herzens  und  der  Blutgefasse,  p.  282. 
3  Odes,  II.,  2.     On  the  form  of  ascites  alluded  to  by  Horace 
cf.  Parkes  Weber,  British  Med.  /.,  1916,  II.,  p.  200. 


126          IDicious  Circles  in  Disease 

Indeed  with  a  sensitive  introspective  individual  the 
mere  idea  of  possessing  a  floating  kidney  may  become 
an  obsession  stirring  up  a  host  of  subjective  sym- 
ptoms. 

Such  undue  mobility  of  the  kidney  is  frequently 
associated  with  visceroptosis,  the  symptoms  of  the 
two  disorders  merging  into  one  another. 

Hydronephrosis.  Hydronephrosis  is  a  serious 
lesion  which  may  result  from  undue  mobility  of  the 
kidneys,  when  nephroptosis  leads  to  kinking  of  the 
ureter  and  renal  vessels,  followed  by  congestion  and 
retention  of  urine  and  consequently  by  increased 
nephroptosis. 

The  origin  of  the  ureter  is  normally  at  the  most 
favourable  part  of  the  pelvis  for  the  escape  of  urine. 
As  the  kidney  descends,  however,  it  revolves  on  a 
sort  of  pivot,  leaving  the  uretero-pelvic  junction  at  a 
higher  level,  so  that  the  escape  of  urine  is  more  and 
more  impeded.1  The  condition  indeed  once  started 
grows  automatically  worse  ;  the  kinked  ureter  causes 
more  and  more  obstruction  to  the  escape  of  urine, 
while  the  increased  weight  of  the  kidney  due  to 
the  venous  congestion  and  retained  urine  aggravates 
the  kink.  The  resulting  hydronephrosis  leads  to  a 
gradual  disorganisation  of  the  renal  functions  and 
to  a  destruction  of  the  renal  tissues  (jplate  VI.  b). 
In  course  of  time  the  whole  gland  may  be  destroyed, 
nothing  but  a  thin-walled  sac  being  left  to  mark 
the  site  of  the  original  kidney.2 


1  Kelly   and  Burnam   give  some  illustrations  showing  the 

gradual  change  in  the  level 'of  the  uretero-pelvic 
junction.  Diseases  of  the  Kidneys,  Ureters  and 
Bladder,  I.,  pp.  526,  531. 

2  In  renal  tuberculosis  the  gland  may  also   be   totally   de-> 

stroyed  by  the  operation  of  a  Vicious  Circle, 


1Hrinan>  System  127 

In  some  cases  the  insertion  of  the  ureter  into 
the  hilum  may  be  abnormally  high  as  to  leave  a 
pouch  lying  below  the  point  of  insertion  and  always 
full  of  urine.  The  pouch  so  formed  may  compress 
the  ureter,  causing  further  distension  and  further 
compression.  Valvular  folds  and  other  abnormal- 
ities may  lead  to  similar  complications. 

According  to  Shattock  hydronephrosis  and  poly- 
uria  are  sometimes  associated  with  idiopathic  dilata- 
tion of  the  bladder,  the  obstruction  which  has 
led  to  the  hydronephrosis  arising  not  from  organic 
changes  but  from  disordered  innervation.  After 
discussing  alternative  theories  Shattock  writes  : 

"  The  pol3mria  probably  results  from  the  hydro- 
nephrosis, and  there  being  a  persistent  obstruction  a 
Vicious  Circle  arises,  in  which  the  hydronephrosis  brings 
about  polyuria  and  the  resulting  polyuria  brings  about 
a  further  increase  in  the  hydronephrosis."1 

Similar  idiopathic  dilatation  is  met  with  in  the 
case  of  the  oesophagus,  the  stomach  and  the  colon, 
the  probable  cause  being  in  each  case  some  neuro- 
pathic influence. 

Nephrolithiasis.  Reciprocal  conditions  are 
established  in  connection  with  renal  calculi,  which 
originate  with  the  deposition  in  the  urinary  passages 
of  colloid  or  albuminous  matters  such  as  mucus, 
blood  or  pus.  Within  the  meshes  of  this  organic 
framework  uric  acid  or  other  deposits  are  entangled 
and  agglutinated  into  a  nucleus,  with  consequent 
irritation  of  the  lining  membranes.  This  irritation 
then  leads  to  further  exudation  of  colloid  matters, 
which  in  turn  collect  fresh  deposits  and  provoke 
fresh  irritation.  In  this  way  the  process  continues, 
while  the  stone  gradually  increases  in  size.  On  the 

lProc.  Roy.  S.  of  Med.  (1909),  II,  (iii.),  (Pathology],  p.  97. 


128 iptdous  Circles  in  Disease 

other  hand  secondary  calculi  result  from  infective 
processes,  generally  associated  with  stagnation  of 
the  urine  and  precipitation  of  phosphates,  the 
resulting  concretion  forming  the  nucleus  of  a  calculus. 
From  this  point  the  process  perpetuates  itself 
automatically  as  described  above. 

Much  the  same  sequence  occurs  in  cases  of 
pyo-nephrosis  complicated  by  a  calculus. 

Morris  writes  : 

"The  relation  between  renal  calculi  and  pyo-nephrosis 
is  a  double  one.  On  the  one  hand  the  calculus  may  be, 
and  frequently  is,  the  cause  of  the  pyo-nephrosis,  but, 
on  the  other  hand,  it  may  be  secondary  and  arise  from 
the  phosphatic  deposits  of  the  alkaline  urine  in  the 
renal  cavity."1 

II.    THE   URETERS 

Simple  tubes  such  as  the  ureters  are  not  so  often 
associated  with  circular  reactions  as  are  complex 
organs.  Moreover  several  of  the  ureteric  disorders, 
e.g.  those  met  with  in  nephroptosis  and  hydrone- 
phrosis,  have  been  referred  to  in  connection  with 
disorders  of  the  kidneys. 

There  are  however  one  or  two  additional  ones 
which  must  be  mentioned. 

Calculus.  A  renal  calculus  in  its  progress  to- 
wards the  bladder  may  be  impacted  in,  and  block, 
the  ureter,  setting  up  inflammation  of  the  mucous 
lining.  This  inflammation  may  aggravate  the  ob- 
struction, and  by  causing  stagnation  of  urine  lead 
to  an  increase  in  the  size  of  the  stone  through 
phosphatic  accretion. 

If  retained  for  a  length  of  time  the  calculus  may 
give  rise  to  a  diverticulum  in  which  urine  accumu- 

1  Surgical  Diseases  of  the  Kidney  and  Ureter,  I.,  p.  446. 


System  129 


lates.     This  also  leads  to  growth  of  the  calculus  and 
to    progressive    enlargement    of    the    diverticulum. 

Dilatation.  Matthews  Duncan  draws  attention 
to  a  curious  condition  in  which  frequent  micturition 
leads  to  narrowing  of  the  vesical  orifices  of  the 
ureters,  followed  by  dilatation  of  the  higher  portions 
of  the  ureter.  The  narrowing  in  its  turn  perpetuates 
excessive  secretion  and  frequent  micturition,  and  so 
the  process  continues. 

Duncan  writes  : 

"  In  cases  of  diabetes  insipidus  the  ureters  are  often 
found  dilated,  as  also  the  kidneys.  This  curious  cir- 
cumstance seems  to  be  explained  by  some  recent  obser- 
vations which  almost  prove  that  the  disease  known  as 
wetting  of  the  bed  in  children  is  the  cause  in  some  cases 
of  dilatation  of  the  ureter  and  of  the  kidney,  and  of 
danger  and  even  death.  This  wetting  of  the  bed  or 
frequent  urination  in  children  is  far  from  being  a  com- 
plaint to  be  considered  as  altogether  of  trifling  import- 
ance. In  these  cases  retention  in  the  ureter  may  occur, 
and  it  is  explained  by  supposing  that  contraction  of  the 
bladder  leads  to  the  frequent  urination,  and  also  to 
closure  of  the  vesical  orifices  of  the  ureters,  produces 
dilatation  of  them,  dilatation  of  the  kidneys  and  danger 
of  death.  This  theory  will  also  apply  to  diabetes 
insipidus  ;  and  if  it  is  so,  you  have  another  example 
of  the  Vicious  Circle.  There  is  a  large  quantity  of  urine, 
which  leads  to  frequent  urination  :  frequent  urination 
leads  to  obstruction  of  the  ureters  at  their  vesical 
orifices,  and  partial  obstruction  of  the  ureters  leads  to 
excessive  secretion  ;  the  excessive  secretion  requires 
frequent  emptying  ;  the  frequent  emptying  produces 
obstruction  of  the  ureters  ;  and  the  obstruction  of  the 
ureters  leads  to  excessive  secretion,  and  so  on."1 

In  other  cases  the  opening  of  the  ureter   into  the 
bladder  may  be   abnormally  small,    impeding  the 


Clinical  lectures  on  Diseases  of  Woman,  p.  82. 


IDicione  Circles  in  Disease 


flow  of  urine,  and  giving  rise  to  a  sacciform  dilatation. 
This  dilatation  may  in  turn  further  diminish  the 
opening  and  thus  complete  the  round. 

III.     THE    BLADDER    AND    PROSTATE 

Cystitis.  Cystitis  may  be  complicated  by  various 
self  -perpetuating  conditions.  One  of  these  is  the 
congestion  and  irritability  of  the  neck  of  the  bladder 
associated  with  increased  frequency  of  micturition. 

Mansell  Moullin  writes  : 

"  The  tissues  become  more  and  more  swollen.  The 
epithelium  becomes  abraded,  or  perhaps  a  small  fissure 
is  formed  ;  the  neck  of  the  bladder  becomes  the  seat 
of  an  intense  burning  pain,  which  is  made  infinitely 
worse  by  the  spasmodic  contraction  of  the  muscles 
around  it,  and  a  Vicious  Circle  is  established.  The 
irritation  at  the  neck  of  the  bladder  causes  increased 
frequency  ;  and  the  increased  frequency  makes  the 
irritability  worse,  until  at  last  the  patient  is  reduced  to 
a  condition  of  the  utmost  misery."1 

Decomposition  of  the  urine  is  another  self- 
aggravating  factor,  owing  to  the  carbonate  of 
ammonia  which  is  formed  and  which  increases  the 
cystitis. 

Leroy  d'Etiolles  writes  : 

"  In  cases  of  phosphatic  gravel,  the  urine  is  ammon- 
iacal,  irritating  and  caustic  to  the  mucous  membrane 
of  the  bladder,  the  inflammation  of  which,  by  generating 
muco-pus,  becomes  in  its  turn  a  cause  of  alkalinity  and 
of  catarrh,  forming  thus  a  truly  Vicious  Circle  in  patho- 
logy, from  which  there  is  no  exit  without  first  altogether 
changing  the  composition  of  the  urine."2 

1  Enlargement  of  the  Prostate,  p.  125. 

2Traite  de  la  Gravelle,  p.  510.     Cf.  also  Pick  and  Hecht, 
Clinical  Symptomatology,  p.  599. 


1ftrinan>  System  131 

Calculus.  Some  interesting  reciprocal  relations 
are  established  during  the  growth  of  a  vesical 
calculus,  whether  such  calculus  has  descended  from 
the  kidney  or  has  been  primarily  formed  in  the 
bladder.  If  a  small  nucleus  slips  into  a  healthy 
bladder,  the  irritation  usually  causes  the  calculus 
to  be  surrounded  with  an  envelope  of  mucus  in 
which  successive  layers  of  crystals  are  deposited. 
The  growth  of  the  stone  then  proceeds  in  an  acid 
medium,  the  film  of  colloid  being  ever  ready  to 
attract  fresh  crystals  of  uric  acid  (or  other  substance) 
from  the  urine  by  molecular  coalescence,  while 
the  enlarging  stone  keeps  up  the  irritation  and 
causes  more  and  more  mucus  to  be  secreted. 

Sooner  or  later,  however,  bacterial  infection 
generally  ensues,  leading  to  cystitis.  The  film 
of  mucus  then  becomes  a  nidus  for  the  deposit  of 
phosphatic  accretions,  and  the  growth  of  the  calculus 
proceeds  in  an  alkaline  medium.  The  growing 
calculus  increases  the  irritation,  while  the  irritation 
leads  to  further  deposits  of  phosphates,  thus  adding 
to  the  size  of  the  concretion  (plate  VI.  c). 

Retention  of  Urine.  A  striking  example  of  a 
circular  reaction  is  presented  by  retention  of  urine 
caused  by  prostatic  hypertrophy.  The  venous  plex- 
uses surrounding  the  prostate  are  always  of  ample 
size  and  undergo  further  dilatation  in  elderly  men. 
This  explains  how  it  is  that  when  an  enlarged 
prostate  is  congested,  a  considerable  increase  in  the 
size  of  the  gland  results,  sufficient  in  many  cases  to 
cause  complete  retention.  The  pressure  of  the 
accumulated  urine  in  turn  aggravates  the  venous 
engorgement,  these  two  factors  acting  reciprocally 
on  each  other.  J.  L,.  Joyce  has  observed  a  marked 
diminution  in  the  size  of  the  prostate  as  soon  as 
the  bladder  had  been  evacuated  by  catheterisation 

(plate  vi.  d). 


132  IDicious  Circles  in  Disease 

Desnos  and  Minet  thus  describe  the  sequence  of 
events  : 

"  The  mechanism  of  the  retention  is  clear.  The 
rapid  increase  in  size  of  the  lateral  lobes  brings  them 
into  contact,  the  whole  gland  being  compressed  by 
the  periprostatic  plexuses.  Further  the  congested 
and  oedematous  mucosa  forms  a  plug  which  obstructs 

the   neck  of  the   bladder Meanwhile   urine   is 

accumulating  behind  the  plug  and  distending  the 
bladder.  The  pressure  of  the  liquid  in  this  reservoir 
aggravates  the  venous  congestion,  until  the  obstruction 
at  the  neck  of  the  bladder  becomes  insuperable."1 

In  some  cases  of  prostatic  hypertrophy  the 
enlarged  middle  lobe  projects  into  the  bladder  like 
a  cone  in  such  a  way  that  the  contained  urethra 
may  be  closed  by  pressure  of  the  urine  on  the  outside 
of  the  cone.  The  enlarged  lobe  may  also  fall  over 
and  close  the  urethral  orifice  like  a  ball-valve,  as 
soon  as  the  bladder  contracts.  The  greater  the 
straining  to  evacuate  the  bladder,  the  more  tightly 
is  the  orifice  closed  ;  the  tighter  the  closure  the 
greater  the  straining.2 

Chronic  retention  frequently  causes  the  trigone 
to  yield  under  the  continual  pressure,  giving  rise 
to  a  thin-walled  post-prostatic  pouch.  When  once 
formed,  this  pouch  leads  to  further  retention  of 
urine,  to  increased  straining  and  eventually  to  further 
bulging.  Occasionally  the  pouch  has  assumed  di- 
mensions equal  to  those  of  the  bladder  itself. 

Maladies  des  Voies  Urinaires,  p.  411.  Cf.  also  Guyon, 
Lecons  Cliniques  sur  les  Maladies  des  Voies  Urinaires, 
II.  p.  397  f.  ;  Fiirbringer,  Die  Krankheiten  der 
Harn-  und  Geschlechtsorgane,  p.  313. 

2  An  illustration  of  such  hypertrophy  is  given  by  Wallace 
in  Practitioner',  1905,  II.,  p.  305.  Other  self-per- 
petuating conditions  are  described  by  Frisch,  Die 
Krankheiten  der  Prostata,  pp.  in,  140. 


Iflrinan?  System  133 

Atony  of  the  bladder  is  another  occasional  compli- 
cation, being  due  to  over-stretching  and  consequent 
weakness  of  the  vesical  walls  (jplatC  VI.  e). 

Lewis  writes  : 

"  Prolonged  or  repeated  retention,  with  overstretch- 
ing of  the  organ,  from  any  cause  whatever,  results  in 
weakening  of  the  detrusor  muscles,  reducing  their 
contractibility  and  producing  the  condition  called 
atony  ;  while,  on  the  other  hand,  atony  itself  contri- 
butes to  further  retention  by  reason  of  the  inability  of 
the  weakened  muscles  to  expel  the  urine.  Thus  is 
established  a  Vicious  Circle  that  forms  the  intimate 
relation  between  the  two  conditions."1 

Several  artefacts  may  be  created  by  the  surgical 
interference  that  may  be  required  in  diseases  of 
the  bladder. 

For  example,  catheterisation  is  often  an  indispen- 
sable operation,  although  there  is  a  risk  of  its 
increasing  the  existing  inflammation. 

Thompson  writes  : 

"  The  cystitis,  on  the  one  hand,  and  the  catheterism, 
on  the  other,  exercise  mutually  inimical  influences,  and 
the  patient  becomes  the  victim  of  a  Vicious  Circle  of 
actions,  in  which  an  absolutely  indispensable  remedy, 
the  catheter,  aggravates  the  inflammation  of  the  bladder 
which  therefore,  in  its  turn,^demands  the  instrument 
with  increasing  frequency."2 

Another  complication  frequently  occurred  in  for- 
mer days  when  lithotrity  was  prolonged  over  several 
sittings.  Cystitis  necessitated  lithotrity,  while  the 
resulting  fragments  of  crushed  stone  increased  the 
cystitis. 


Surgery,  IV.,  p.  299. 
Clinical  Lectures  on  Diseases  of  the  Urinary  Organs,  p.  147. 


134  IDtctoug  Circles  in  Disease 

Guyon  writes  : 

"  In  former  days  when  lithotrity  was  performed  at 
short  and  numerous  seances  without  chloroform,  the 
fragments  of  crushed  stone  were  left  in  the  bladder. 
These  more  or  less  jagged  fragments  were  often  of 
considerable  size  and  increased  the  irritation  caused  by 
the  manipulations,  which  were  done  without  any 
attempt  at  anaesthesia.  Indeed  the  fragments  caused 
far  more  irritation  than  did  the  original  calculus. 
Attacks  of  cystitis  followed,  which  were  difficult 
either  to  avoid  or  to  deal  with,  since  they  were  directly 
due  to  curative  treatment,  and  since  their  treatment 
always  required  a  more  or  less  considerable  number  of 
seances.  There  was  no  possible  escape  from  this 
Vicious  Circle."1 

Neuroses.  Irritability  of  the  bladder  is  not 
an  uncommon  complication  of  neurasthenia  and  in 
turn  perpetuates  that  condition.  Thus  there  are 
persons  who,  in  view  of  an  imaginary  inconvenience 
they  may  be  temporarily  exposed  to  during  a  long 
railway  journey,  go  on  for  days  previously  mictura- 
ting  every  few  minutes.  They  thus  acquire  a  habit 
which  may  be  permanent. 

Moreover  the  greater  the  frequency  of  micturition 
the  more  abundant  the  secretion  of  urine.  Here 
also  there  is  a  reciprocity  of  cause  and  effect.  Other 
neuropaths  suffer  from  retention  ;  the  harder  they 
strain  in  order  to  pass  their  water  the  less  they  are 
able  to  do  so. 

Such  neurotic  retention  is  doubtless  due  to  an 
involuntary  contraction  of  the  compressor  urethrae 
which  totally  prevents  the  flow  of  urine,  and  such 
retention  in  its  turn  increases  the  nervousness  and 
incapacity.  The  condition  is  closely  allied  to  stam- 
mering of  the  urinary  organs  which  Sir  James 

^a  Vessie  et  la  Prostate,  p.  699. 


KHrinan>  System  135 

Paget  has  described  : 

"  Stammering  urinary  organs  are  not  rare  ;  and 
they  may  be  known  by  observing,  sometimes  in  the 
same  person,  the  exact  parallelism  between  the  diffi- 
culty of  expelling  urine  and  that  of  expelling  the  air  in 
the  ordinary  speech-stammering.  The  patient  can 
often  pass  his  urine  without  any  trouble,  especially  at 
customary  times  and  places  ;  and,  when  he  does  so, 
the  stream  is  full  and  strong,  and  he  has  '  nothing  the 
matter  with  him.'  But,  at  other  times,  he  suffers  all 
the  distress  that  he  might  have  with  a  very  bad  urethral 
stricture.  He  cannot  pass  a  drop  of  urine  ;  or,  after  a 
few  drops,  there  comes  a  painful  check  ;  and  the  more 
he  strains,  the  less  he  passes  ;  and  then  complete 
retention  may  ensue,  and  over-filling  of  the  bladder."1 

Another  neurosis  due  to  exaggerated  reflex  irrita- 
bility is  nocturnal  enuresis.  Some  temporary  de- 
rangement may  start  the  habit,  and  this,  if  fre- 
quently repeated,  may  so  act  on  the  impressionable 
nervous  system  of  a  child  as  to  persist  after  the 
removal  of  the  exciting  cause. 

IV.     THE    URETHRA 

Congestion.  In  acute  gonorrhoea  the  mucous 
membrane  may  be  so  congested  as  to  lead  to  retention 
of  urine.  Such  retention  in  turn  aggravates  the 
congestion  and  so  increases  the  obstruction.  The 
more  prolonged  the  retention  the  greater  the  swell- 
ing, and  vice  versa.  The  severe  straining  associated 
with  tight  strictures  sets  up  a  similar  hyperaemic 
condition  of  the  urethra  which  increases  the  stricture 

(plate  vi.  f). 

Urethral  retention  associated  with  uterine  dis- 
placements is  described  in  the  next  Chapter. 

Urethrocele.  Strictures  of  the  urethra  are  not 
uncommonly  complicated  by  retro-strictural  dilata- 

1  Clinical  Lectures  and  Essays,  p.  78. 


136  IDicious  Circles  in  ^Disease 

tions.  These  dilatations  contain  decomposing  urine 
and  sometimes  a  calculus,  and  may  be  so  situated  as 
to  press  further  on  the  strictured  urethra  and  to 
provoke  dysuria.  Thus  the  dysuria  is  both  cause 
and  result  of  the  dilatation. 

Urethroceles  may  also  arise  from  catarrh  of  the 
urethra  through  relaxation  of  the  walls  and  the 
gradual  separation  of  muscular  fibres.  I/ittle  by 
little  the  urine  pushes  aside  the  weakened  tissues  and 
forms  a  sac  in  which  urine  accumulates.  Decom- 
position soon  follows  and  tends  to  increase  the 
urethritis.1 


Thomas,  Diseases  of   Women,  p.  238. 


Chapter  Eight 


THE    SEXUAL   SYSTEM 


HE  intimate  relations  that  exist  between 
different  portions  of  the  sexual  system 
as  well  as  between  the  sexual  and  the 
other  systems  of  the  body  would  on  a 
priori  grounds  lead  us  to  expect  the 
presence  of  morbid  circular  reactions  in  cases  of 
sexual  disease.  Such  in  fact  is  the  case. 

The  two  sexes  will  be  dealt  with  separately. 

I.     DISORDERS    IN   THE   MALE 

Masturbation.  A  common  example  is  presented 
by  neurasthenia  associated  with  sexual  malpractices. 
An  exaggerated  tendency  to  self-abuse  is  usually 
the  result  of  a  neurotic  predisposition  and  in  turn 
increases  any  existing  nervous  weakness. 

Oppenheim  writes  : 

"  In  many  cases  we  have  a  Vicious  Circle  ;  the 
tendency  to  masturbation  is  in  itself  a  symptom  of  a 
neuropathic  diathesis,  and  the  masturbation  again 
gives  rise  to  a  crowd  of  nervous  disorders."1 

Miiller  also  describes  the  process  : 

"  In  neurasthenic  persons  of  both  sexes,  especially 
if  unmarried,  there  is  a  tendency  to  satisfy  the  sexual 
instinct  by  means  of  masturbation.  Indeed  it  is 
often  difficult  to  decide  whether  the  masturbation 
should  be  regarded  as  a  result  or  as  a  cause  of  the 
sexual  neurasthenia,  since  a  circulus  vitiosus  has 
generally  been  established."2 

aLehrbuch  der  Nervenkrankheiten  (1913),  II.,  p.  1486.  (Eng. 

Ed.,  1911,  II.,  pp.  1125-6). 
2  Neurasthenic,  p.  i8r. 


138  IDtcioug  Circles  In 


The  serious  results  of  sexual  malpractices  are 
frequently  seen  in  our  lunatic  asylums.  Mental 
deficiency  is  unquestionably  both  cause  and  effect 
of  such  malpractices. 

Self-abuse  may  also  result  in  physical  disorders 
such  as  a  chronic  prostatitis  and  spermocystitis 
which  maintain  a  state  of  erethism  which  favours 
an  injurious  degree  of  self-indulgence.  In  other 
cases  there  is  a  posterior  urethritis  and  frequent 
spermatorrhoea,  the  two  aggravating  each  other. 

The  latter  disorders  are  said  to  be  especially  due 
to  congressus  interruptus. 

Fiirbringer  writes  : 

"  A  condition  of  spermatorrhoea  or  of  too  facile 
pollution  is  almost  invariably  provoked  ;  moreover 
in  addition  to  the  sexual  neurasthenia  a  chronic  state 
of  irritability  of  the  posterior  urethra  is  brought  on, 
which  gives  rise  to  a  circulus  vitiosus."1 

Sturgis  lays  emphasis  on  the  same  disorder  : 

"  There  is  a  constant  hankering  for  more  inter- 
course. This  inordinate  desire  gives  rise  to  more 
frequent  copulation,  until  hyperresthesia  is  set  up  in 
the  prostatic  urethra,  which  is  sought  to  be  relieved 
by  more  coitus,  and  thus  a  Vicious  Circle  is  established. 
The  more  the  patient  copulates  the  more  the  irritation, 
and  the  greater  the  irritation  the  more  the  desire  for 
coition."2 

Spermatorrhoea.  Injurious  circular  reactions 
also  occur  apart  from  self  -abuse.  Thus  there  may 
be  an  irritable  condition  of  the  nervous  system 
which  relieves  itself  too  frequently  by  seminal 
discharges.  Such  excessive  discharges  frequently 
perpetuate  the  irritability. 

'Storungen  der  Geschlechtsfunctionen  des  Mamies,  p.  41. 
2  Prostatorrhea    Simplex    and    Urethrorrhea    ex    Libidine. 

/.  of  Cut.  and  Genito-U  rinary  Diseases,  New  York 

(1898),   XVI.,   p.    270. 


Seyual  System 


139 


Ba/s 


^ 


(c)  VARFCOCELE 


(d)  VAQINISMUS 


(e)  PROLAPSE  OF  UTERUS 


(f)  RETROVERSION  OF 
GRAVID  UTERUS 


plate  vii.— circles  associated  with  tbe 
Seyual 


140  lDtciou0  Circles  in  Disease 

Beard  writes  : 

"  Occasional  seminal  discharges  in  the  healthy  and 
unmarried  are  physiological — that  is,  they  are  not 
symptoms  of  disease.  Such  involuntary  discharges, 
when  excessively  frequent,  may  be  both  results  and 
causes  of  disease,  indicating  an  abnormal,  usually 
an  exhausted,  state  of  the  nervous  system,  and  in  turn 
reacting  on  the  nervous  system,  increasing  the  very 
exhaustion  that  caused  it."1 

There  is  also  an  element  of  hypochondriasis 
which  complicates  these  disorders,  and  makes  them 
difficult  to  cure. 

Paget  thus  describes  them  : 

"  The  patients  are  full  of  apprehension,  unable  to 
divert  their  minds  from  their  sexual  functions,  con- 
stantly watchful  of  their  sensations  and  making  them 
constantly  more  intense.  And  further  mischief  follows 
from  all  this :  for  the  direction  of  the  mind  to  the  sexual 
organs  makes  both  them  and  the  parts  of  the  sexual 
system  associated  with  them  more  and  more  irritable  ; 
it  increases  the  secretion  of  the  seminal  fluid  and 
hurries  its  discharge.  The  mind  thus  multiplies  the 
source  of  its  own  misery."2 

Spermatorrhoea  is  often  associated  with  insomnia, 
the  two  disorders  reacting  on  each  other. 

Holmes  writes  : 

"  The  emissions  are  most  usually  associated  with, 
and  probably  result  from,  erotic  dreams  and  images, 
which  often  disturb  sleep  ;  and  as  the  patient's  mind 
may  be  at  the  same  time  worried  by  the  emissions 
which  he  fears  and  of  which  he  is  ashamed,  a  definite 
insomnia  may  result.  And  as  insomnia  naturally 

1  Nervous    Exhaustion,    p.    70.     Cf.    also    E.    Jendrassik, 

Volkmann's  Sammlung  Klin.  Vortrage  (Innere  Med- 
izin,  1906,  No.  128-9. 

2  Clinical  Lectures  and  Essays,  p.  279. 


Seyual  Spetem  141 

depresses  his  energies  and  lowers  his  resistance,  a 
Vicious  Circle  is  established,  which  can  easily  produce 
the  intensest  form  of  neurasthenia."1 

Excessive  irritability  of  the  erection  and  ejacula- 
tion centres  may  be  brought  about  by  any  local 
irritation  along  the  genital  tract,  reciprocal  relations 
being  usually  present.  A  common  illustration  of 
this  is  seen  in  gonorrhoea  which  renders  the  sexual 
centres  unduly  sensitive,  while  these  latter  in  turn 
increase  the  hyperaesthesia  of  the  urethra,  especially 
of  its  prostatic  and  bulbous  sections. 

Krafft-Ebing  writes  : 

"  It  must  always  be  borne  in  mind  that  any  peri- 
pheral irritation  in  the  sexual  tract  of  the  male,  what- 
ever the  cause,  .  .  .  reacts  on  the  ejaculation  centre 
and  induces  a  chronic  state  of  increased  irritability.  This 
condition  of  irritability  also  spreads  to  the  erection 
centre  which  is,  both  anatomically  and  functional^, 
so  closely  connected  with  the  ejaculation  centre.  A 
circulus  vitiosns  is  thus  established,  since  the  abnormal 
stimulation  of  the.  erection  centre  gives  rise  in  its 
turn  to  a  peripheral  hyperaemia  and  irritation,  some- 
times even  to  ejaculation,  which  again  reacts  injuri- 
ously on  the  centres."2 

Impotence.  In  the  healthy  individual  there  is  a 
reflex  physiological  Circle  formed  by  the  reciprocal 
influence  on  each  other  of  the  central  nervous  system 
and  the  peripheral  sexual  organs,  and  on  the  har- 
monious operation  of  these  correlations  depends  the 
potentia  coeundi.  Any  psychical  or  physical  disturb- 
ance of  such  correlations,  on  the  other  hand,  may 
result  in  impotence  ;  for  example,  the  fear  of 
impotence  may  suffice  to  cause  such  disability. 

1  Practitioner,  1911,  I.,  pp.  51,  53- 

2  Nothnagel,  Sp'ecielle  Pathologic  und  Therapie.     Nervositat 

und    Neurasthenische    Zustande,    by    Krafft-Ebing, 
p.  191. 


142  IDtcioug  Circles  in 


Such  fear  is  sometimes  purely  psychical  and  has 
no  solid  foundation  ;  in  other  cases  a  trivial  disorder 
may  arouse  such  a  powerful  obsession  that  the 
potentia  coenndi  vanishes.  Over-anxiety  defeats  its 
end  own,  while  on  the  other  hand  success  breeds 
success. 

Morris  writes  : 

"  vSome  slight  physical  imperfection  or  want  of 
general  tone  may  give  rise  to  a  feeling  of  fear  of  impo- 
tence or  of  mistrust  of  self,  or  an  exaggerated  idea  of 
the  effects  of  past  masturbation,  or  the  memory  of  an 
unsatisfactory  coitus  may  take  possession  of  the 
mind,  and  an  imaginary  or  false  impotence  will  be  the 
result.  The  mere  thought  that  a  sexual  intercourse 
will  be  impossible  or  unsatisfactory  is  quite  sufficient 
cause  to  make  it  so."1 

Paraphimosis.  Paraphimosis  may  be  a  self- 
aggravating  disorder  when  the  constricting  ring  of 
preputial  skin  and  mucous  membrane  leads  to  venous 
engorgement  of  the  glans,  and  this  engorgement 
causes  the  ring  to  grow  tighter  and  tighter.  The 
strangulation  leads  to  congestion  and  this  in  turn 
aggravates  the  strangulation  (JMatC  VII.  a). 

Balano-Posthitis.  Another  circular  reaction  may 
be  observed  when  the  smegma  under  the  prepuce 
is  allowed  to  collect  and  decompose.  Especially  is 
this  likely  to  happen  where  the  orifice  is  narrow  so 
that  the  prepuce  cannot  be  readily  withdrawn. 
An  inflamed  hypersemic  condition  of  the  mucous 
surface  of  the  prepuce  is  then  kept  up  which  narrows 
the  orifice  more  and  more.  The  phimosis  causes 
retention  of  the  smegma  ;  the  retention  sets  up 
balano-posthitis  and  increases  the  phimosis  (JMatC 
VII.  b).  Preputial  calculi  occasionally  form  and 
add  to  the  irritation. 

1  Injuries  and  Diseases  of  the  Genital  and  Urinary  Organs, 
p.  43.  Cf.  also  Ziemssen,  Cyclopaedia  of  the  Practice 
of  Medicine,  VIII.,  p.  891. 


Sejrual  System  143 


Corner  writes  : 

"  The  secretion  decomposes  and  irritates  both  the 
glans  penis  and  the  prepuce,  producing  a  chronic 
superficial  balano-posthitis  and  a  deeper  chronic 
inflammation  in  the  prepuce,  causing  its  fibrosis  and 
subsequent  contraction  on  the  glans  penis.  The 
meatus  in  it  also  becomes  contracted  so  that  it  can 
no  longer  be  withdrawn  over  the  glans,  and  the  secre- 
tions under  it  collect  and  ferment,  producing  further 
irritation.  The  greater  the  irritation  of  the  glands  by 
decomposing  secretion,  the  greater  the  amount  of 
secretion  they  produce.  In  this  way  a  Vicious  Circle 
is  established."1 

Varicocele.  In  varicocele  the  tortuous  and  depen- 
dent veins  of  the  pampiniform  plexus  are  enlarged, 
while  the  valves  become  incompetent  and  the  walls 
of  the  veins  thinned.  The  larger  the  veins  the 
greater  the  tension  on  their  walls  ;  the  greater 
the  tension  the  more  do  the  walls  yield.  When 
the  valves  become  incompetent  a  further  aggravating 
factor  is  added  (plate  VII.  c). 

Hydrocele.  Hydrocele  is  usually  attributed  to 
a  disturbance  of  the  mechanism  governing  the 
secretion  of  fluid  into,  and  the  absorption  of  fluid 
out  of,  the  tunica  vaginalis.  When  the  quantity  of 
fluid  secreted  is  increased,  such  increase  may  com- 
press the  effluent  lymphatics  and  so  lead  to  a 
further  accumulation. 

In  other  cases  the  blood-pressure  in  the  spermatic 
artery  may,  owing  to  arterio-sclerosis,  be  unequal  to 
the  task  of  driving  the  blood  through  the  veins. 
Hence  may  result  a  venous  congestion  of  the  testicle 
and  from  time  to  time  a  hydrocele,  leading  in  turn 
to  further  congestion. 


Diseases  in  General  Practice,  p.  398. 


144          IDictoue  Circles  in  Disease 

II.     DISORDERS    IN   THE   FEMALE. 

The  sexual  system  plays  an  even  greater  role  in 
the  life  of  a  woman  than  it  does  in  that  of  a  man. 
Indeed  in  the  former  the  functional  correlations 
between  the  genital  organs  and  the  central  nervous 
system  often  colour  her  entire  outlook  on  life.  We 
should  expect ,  therefore,  that  disease  would  awaken 
many  reverberations  echoing  and  re-echoing  between 
such  sensitive  organs,  and  the  facts  correspond 
with  the  anticipation. 

Neurasthenia.  Neurasthenia  and  local  disease 
of  the  sexual  organs  very  frequently  perpetuate  one 
another. 

Amand  Routh  writes  : 

"We  have  frequently  to  deal  with  a  Vicious  Circle, 
with  local  and  constitutional  states  so  interacting,  that 
no  real  improvement  is  possible  until  both  the  general 
and  local  states  receive  their  due  share  of  attention."1 

Such  a  reciprocation  may  occur  even  in  healthy 
females,  leading  a  natural  out- door  existence  with 
well-filled  leisure  and  no  undue  tendency  to  intro- 
spection. But  the  disorder  is  far  more  prevalent  in 
neuropaths  with  little  to  do  and  little  else  to  think 
about  than  their  own  whims.  General  and  sexual 
ill-health  then  form  the  commonest  combinations, 
each  disorder  feeding  the  other. 

Faure  and  Siredey  write  : 

"  Women  suffering  from  disease  of  the  sexual  organs 
frequently  shew  signs  of  physical  and  moral  depression 
which  is  closely  allied  to  neurasthenia.  Worn  out  by 
their  sufferings,  often  anaemic  through  loss  of  blood  or 
through  prolonged  confinement  to  the  house,  either  in 
bed  or  on  the  sofa,  these  unfortunate  women  grow 
thin  and  feeble,  and  give  way  more  and  more  to  dis- 

1Allbutt,    Playfair   and  Eden,    Gynaecology,    p.    737.     Cf, 
also  Thomas,  Diseases  of  Women,  p.  56, 


Seyual  System  145 

couragement.  They  are  now  entrapped  in  a  Vicious 
Circle,  from  which  escape  is  difficult.  Their  neura- 
sthenia induces  dyspeptic  disorders,  and  their  mal- 
nutrition tends  to  aggravate  their  neurasthenia."1 

This  form  of  illness  is  especially  apt  to  occur 
where  there  has  been  some  physical  or  mental 
drain  on  the  nervous  system.  For  example,  the 
excitement  associated  with  parturition  or  such  a 
local  disorder  as  metritis,  leucorrhrea,  dysmenorrhcea 
or  dyspareunia  may  start  the  morbid  chain  of  events 
in  which  both  the  central  and  peripheral  factors 
play  a  part. 

MacNaughton  Jones  writes  : 

"  All  recent  authorities  agree  that  the  nervous 
system  can,  through  vasomotor  effects  and  central  ner- 
vous influences,  induce  ill-health  and  perversion  of 
functions  in  the  genitalia,  causing,  for  example,  amen- 
orrhcea,  dysmenorrhoea  and  menorrhagia.  The  con- 
verse is  equally  true,  that  morbid  states  of  the  genitalia 
which  lead  to  excess,  diminution  or  absence  of  func- 
tional activity,  will  affect  the  ganglionic  and  central 
nervous  system.  This  '  action  and  reaction'  it  is 
that,  once  the  Vicious  Circle  is  formed,  maintains  the 
ill-health  of  both."2 

One  of  the  commonest  local  disorders  is  hyperses- 
thesia  of  the  ovaries.  Owing  to  the  lowering  of  the 
neuron  threshold  the  woman  is  worried  and  kept 
awake  at  night  by  an  ache  which  would  not  affect 
consciousness,  were  she  less  sensitive.  Her  worry 
and  insomnia  then  perpetuate  her  hyperaesthesia 
and  often  render  life  a  burden  both  to  herself  and 
others.  The  menstrual  period  usually  aggravates 
the  disturbance. 

xTraite  de  Gynecologic  Medico-Chirurgicale,  p.  396. 

2  Practitioner ,  1911,!.,  p.  68.  Cf.  also  Herman  and  Maxwell, 
Diseases  of  Women,  p.  73  ;  Rohin  and  Dalche, 
Traitement  Medical  des  Maladies  des  Femmes,  p.  27. 


146          IDicious  Circles  in  Disease 

Herman  and  Maxwell  write  : 

"  In  chronic  pelvic  pain  with  neurasthenia  effects 
follow  one  another  in  a  Vicious  Circle.  The  patient 
feels  more  severely  the  pelvic  pain  because  her  nervous 
system  is  too  sensitive.  The  persistent  pelvic  pain 
keeps  her  nervous  system  weak  and  sensitive  and  further 
weakens  it."1 

Chlorosis.  Chlorosis,  although  usually  a  cause  of 
scanty  menstruation,  at  times  leads  to  menorrhagia 
and  metrorrhagia,  which  in  turn  aggravate  the 
chlorosis. 

Matthews  Duncan  writes  : 

"  When  a  woman  is  chlorotic  she  fortunately  has 
generally  amenorrhcea,  but  if  not,  she  will  be  very 
likely  to  have  menorrhagia.  And  you  have  here  an 
illustration  of  a  Vicious  pathological  Circle.  The 
menorrhagia  increases  the  chlorosis,  and,  vice  versa,,  the 
chlorosis  aggravates  the  menorrhagia."2 

Croom  writes  in  the  same  strain  : 

"These  cases  are  amongst  the  most  difficult  to  treat, 
because  they  interact  in  such  a  way  as  to  produce  a 
Vicious  pathological  Circle — the  drain  on  the  system  by 
the  haemorrhage  tending  to  aggravate  the  very  systemic 
condition  which,  in  its  turn,  leads  to  the  menorrhagia."8 

It  is  difficult  to  account  for  the  menorrhagia  when 
the  body  can  so  ill  spare  the  loss  of  blood.  Possibly 
the  explanation  lies  in  the  increased  volume  or 
low  specific  gravity  or  coagulability  of  the  blood,  or 
in  a  faulty  nerve  control. 

Pruritus  Vulvse.  Pruritus  vulvse  is  at  times 
complicated  by  a  circular  reaction.  The  irritation 
may  be  purely  nervous,  but  it  is  more  often  due  to 


Diseases   of  Women,    p.    79.     Cf.    also   British   Med.   /., 

1910,  I.,  p.  183. 

2  Lectures  on  the  Diseases  of  Women,  p.  124. 
3Allbutt,  Pla}rfair  and  Eden,  Gynaecology,  p.  85. 


Seyual  System  147 


some  local  disease.  In  either  case  the  severe  itching 
leads  to  scratching,  and  the  scratching  abrades  the 
skin  and  accentuates  the  itching. 

Gibbons  writes  : 

"  Scratching  produces  temporary  relief,  and  with  it 
those  changes  in  the  tissues  which  themselves  lead  to 
scratching,  so  that  a  Vicious  Circle  is  established.  The 
scratching  eases  the  itching  for  a  time,  but  the  very 
relief  which  is  brought  about  is  at  the  cost  of  minute 
changes  in  the  tissu.es  which  cause  further  scratching."1 

Vulvitis  associated  with  vaginal  discharges  may  be 
complicated  in  much  the  same  way  ;  the  irritation 
and  rubbing  reciprocally  provoke  each  other  ;  the 
disorder  is  specially  common  in  young  girls. 

Brocq  writes  : 

"  The  child  experiences  a  more  or  less  acute  sense  of 
burning  and  itching  which  compels  it  to  scratch  itself. 
The  scratching  merely  serves  to  augment  the  inflam- 
mation."2 

Allied  to  vulvitis  is  a  condition  resembling  balano- 
posthitis  in  the  male.  If  the  smegma  secreted  by 
the  vulvar  or  clitoridean  glands  is  allowed  to  accum- 
ulate, decomposition,  inflammation  and  excoriation 
of  the  mucous  surfaces  may  result,  leading  to 
increased  secretion  and  accumulation. 

Vaginismus.  Vaginismus  is  another  disorder  due 
largely  to  an  abnormal  nervous  excitability  of  the 
woman,  combined  with  irritability  of  the  external 
sexual  organs.  The  general  and  local  conditions  aid 
and  abet  each  other  (JMatC  VII.  d). 

Robin  and  Dalche  write  : 

"  It  matters  little  whether  the  general  state  of  health 
is  the  cause  or  the  effect  of  the  local  condition,  for  the 
two  react  on,  and  aggravate,  each  other  in  a  Vicious 


1  British  Med.  /.,  1912,  I.,  p.  471. 

2  Dermatologie  Pratique,  I.,  p.  348. 


148          Oicious  Circles  in  Disease 

Circle.  Treatment  must  be  directed  to  the  nervous 
system,  to  the  dyspepsia,  to  any  visceral  ptosis,to  the 
anaemia,  in  fact  to  the  entire  organism  which  is  out  of 
order.  Only  when  this  is  done  will  the  local  treatment 
of  the  vulvar  irritation  prove  efficacious  and  per- 
manent."1 

Vaginismus  is  closely  associated  with  dyspareunia 

which  is  often  due  to  a  slight  laceration  of  the  hymen. 

The  difficulty  of  coitus  causes  more  force  to  be  used 

and  as  a  result  the  hymen  suffers  further  injury. 

Berkeley  and  Bonney  write  : 

"  In  patients  such  as  these  a  dual  condition  exists, 
one  physical  and  the  other  psychical.  The  orifice  is 
undoubtedly  tender — the  pain  that  results  in  attempts 
at  intercourse  abolishes  the  sex-sense  and  inhibits  the 
flow  of  mucus  which  normally  under  the  influence  of 
sexual  excitement  should  assist  the  act.  In  conse- 
quence, resistance  efforts  are  made,  both  voluntarily 
and  involuntarily,  the  chief  of  which  consists  in  a 
spasmodic  contraction  of  the  levatores  ani  muscles 
(vaginismus)  whereby  the  orifice  is  narrowed  and  the 
act  rendered  yet  more  difficult  and  painful.  Thus  a 
Vicious  Circle  is  established,  its  inception  depending 
upon  the  sensitive  condition  of  the  hymen."2 

Displacement  of  the  Uterus.  A  variety  of 
self -perpetuating  conditions  occur  in  connection  with 
displacement  and  congestion  of  the  uterus,  a  disorder 
which  may  be  caused  in  a  variety  of  ways.  The 
primary  prolapse  leads  to  congestion  and  this 
favours  increased  prolapse  (plate  VII.  e).  Especi- 
ally is  such  a  sequence  common  if  a  woman  returns 
to  hard  work  soon  after  childbirth  before  the  com- 
pletion of  involution.  Not  only  is  the  uterus  bulky 
and  heavy,  but  the  ligaments  are  weak  and  relaxed. 

The  further  the  uterus  descends  in  the  pelvis  the 
greater  will  be  the  interference  with  the  circulation 

^raitement  Medical  des  Maladies  des  Femmes,  p.  284. 
2  Gynaecology,  p.  106. 


Seyual  S£0tern  149 


through  its  walls.  Hence  will  result  a  persistent 
engorgement  of  its  tissues  ending  in  their  hyper- 
trophy. Such  hypertrophy  keeps  up  the  displace- 
ment. 

Complete  procidentia  is  especially  injurious,  since 
the  veins  of  the  broad  ligaments  are  then  so  com- 
pressed that  the  return  of  blood  is  impeded,  resulting 
in  oedema  and  still  greater  weight.1 

Goodell  draws  attention  to  reciprocal  relations 
that  may  be  established  between  the  uterus,  vagina 
and  bladder,  especially  in  connection  with  hyper- 
trophic  elongation  of  the  supra-vaginal  portion  of 
the  cervix  : 

"It  is  a  Vicious  Circle  throughout  ;  the  prolapsing 
organ  —  say  the  vagina  —  tugs  at  the  bladder,  which 
yields,  and  in  turn  lends  its  weight  towards  the  further 
descent  of  the  former  by  alternately  coercing  and  being 
coerced  ;  their  united  action  at  last  begets  the  circular 
hypertrophy  of  the  cervix  ;  the  latter  returns  the 
favour  by  edging  and  nudging  on  the  vagina,  which 
responds  by  still  more  increasing  the  prolapse  of  the 
bladder  and  the  hypertrophy  of  the  cervix,  and  by 
aiding  them  in  drawing  out  the  supra-glandular  portion 
of  the  cervix.  Thus  the  reciprocation  is  kept  up  until 
the  constantly  elongating  and  growing  cervix  has 
attained  length  and  weight  enough  to  act  aggressively."2 

In  some  cases  such  a  hypertrophied  cervix  causes 
great  vaginal  irritation,  acting  much  as  if  it  were 
a  foreign  body  and  exciting  expulsive  efforts.  Such 
efforts  in  their  turn  increase  the  descent  and  hyper- 
trophy.3 

Again  an  elongated  and  protruding  cervix  may  be 
so  strangulated  by  the  vulvar  ring  that  the  return  of 
blood  is  obstructed  ;  the  strangulation  leads  to 


Playfair    and    Eden,    Gynaecology,    p.    197.     Cf. 
also  Thomas,  Diseases  of  Women,  p.  383. 

2  Wessons  in  Gynaecology,  p.  227. 

3  Barnes,  Diseases  of  Women,  p.  623. 


I5Q          Dtcious  Circles  in  2)tgease 

oedema  of  the  cervix  and  this  aggravates  the  strangu- 
lation. The  resulting  swelling  may  be  so  great  that 
considerable  force  may  be  required  for  replacement.1 
The  condition  somewhat  resembles  that  of  penis 
captivus  described  by  Huhner.2 

Salpingitis.  When  mucus  or  pus  collect  in  the 
Fallopian  tube,  congestion  and  obstruction  of  the 
ostium  uterinum  are  liable  to  follow,  giving  rise  to 
hydrosalpinx  or  pyosalpinx.  As  the  retained  secre- 
tions undergo  decomposition,  further  irritation  is  set 
up  which  aggravates  the  obstruction.  In  other 
cases  a  kink  of  the  Fallopian  tube  is  the  primary 
cause  of  retention,  followed  by  a  greater  weight. 
The  greater  weight  increases  the  kink,  and  so  the 
process  continues,  while  the  lumen  grows  steadily 
smaller,  and  the  accumulation  of  secretion  more 
abundant. 

Disorders  of  Pregnancy  and  Parturition.    A 

mechanical  disorder  in  which  there  is  mutuality  of 
cause  and  effect  may  be  brought  about  when  a 
retroverted  gravid  uterus  is  so  impacted  in  the 
pelvis  as  to  press  on  the  urethra  and  cause  retention 
of  urine.  The  distended  bladder  increases  the 
retro  version  ;  the  retro  version  increases  the  retention 

(Iplate  vii.  f). 

Matthews  Duncan  writes  : 

"  In  cases  of  retro  version  of  the  gravid  uterus  the 
retention  of  urine  is  both  cause  and  effect.  In  other 
words  there  is  in  this  disease  what  is  sometimes  called 

a  Vicious  Circle The  replete  bladder  increases 

the  retroversion  and  makes  it,  for  the  time  at  least, 
incurable,  and  it  was  the  retroversion  that  made  the 
retention  of  urine  by  pressure  on  the  urethra.  So  the 

xAn  illustration  of  this  state  of  strangulation  is  given  by 
Herman  and  Maxwell.     Diseases  of  Women,  p.  112. 
2  Disorders  of  the  Sexual  Function,  p.  183. 


Seyual  System  151 

first  is  the  cause  of  the  second,  and  the  second  is, 
inversely,  the  cause  of  the  first,  both  combining  to  form 
a  Vicious  Circle.  In  this  kind  of  retention  there  is 
frequently,  and  probably  always,  a  kind  of  insipid 
diabetes  present."1 

Congestion  of,  and  haemorrhage  into,  the  decidua 
may  also  establish  a  pernicious  circular  reaction. 
Such  haemorrhage  is  very  apt  to  cause  detachment 
of  the  decidua  and  this  in  turn  promotes  further 
haemorrhage.  Abortion  frequently  results  from  the 
process,  which  is  frequently  associated  with  impac- 
tion  of  the  gravid  uterus. 

Kiistner  writes  : 

"  The  broad  ligaments  are  twisted,  .  .  .  the  thin- 
walled  veins  are  compressed  and  their  lumen  diminished, 
resulting  in  congestion  of  the  uterus.  This  congestion 
is  probably  the  usual  cause  of  the  interruption  of  the 
pregnancy  that  so  often  takes  place  and  of  the  abortion 
that  so  often  follows  spontaneously.  The  congestion 
leads  to  haemorrhages  in  the  decidua.  These,  although 
slight  at  the  outset,  lead  to  further  damage  to  tissues, 
and  this  in  turn  to  further  haemorrhage,  until  the  Vicious 
Circle  of  a  commencing  abortion  is  established."2 

Where  there  is  a  threatened  abortion  the  portion 
of  ovum  that  is  first  detached  may  act  somewhat 
like  a  foreign  body  and  provoke  uterine  contractions 
which  cause  further  detachment  and  so  on  until 
abortion  is  complete. 

According  to  Fuchs  a  process  of  reciprocation  may 
be  observed  in  cases  where  an  unusually  large  foetus 
is  associated  with  partus  serotinus  or  deferred 
delivery.  The  dimensions  of  the  giant  foetus  compel 
almost  complete  physical  repose  of  the  mother 


1  Clinical  Lectures  on  the  Diseases  of  Women,  p.  78.     Cf. 

also  Pouliot,  Annales  des  Maladies  Genito-Urinaires, 

1909,   p.  5. 
2Veit,  Handbuch  der  Gynakologie,  I.,  p.  248. 


IDicious  Circles  in  Disease 


during   the    last   weeks    of    her    pregnancy,    which 
repose  further  contributes  to  the  foetal  growth. 

Fuchs  writes  : 

"  The  primary  dimensions  of  the  foetus  compel  the 
pregnant  woman  to  a  life  of  complete  repose  while 
such  repose  promotes  the  further  enlargement  of  the 
child,  thus  completing  the  circulus  vitiosus."1 

Asphyxia  neonatorum  is  frequently  complicated 
by  what  Lenzmann  terms  "  a  very  grave  Vicious 
Circle."  This  will  be  described  in  Chapter  XVII. 

Uterine  inertia  after  delivery  sometimes  per- 
petuates itself  as  a  result  of  the  secondary  dis- 
tention  of  the  uterus  with  blood.  The  condition 
is  especially  liable  to  occur  if  there  is  any  neglect 
in  the  supervision  of  the  uterus  after  delivery.  The 
uterus  may  then  fill  with  blood  without  there 
being  any  external  appearance  of  haemorrhage  and 
the  inertia  is  thus  maintained.2 

Another  post-partum  complication  may  be  associ- 
ated with  uterine  inversion,  when  the  fundus  is 
indented  so  as  to  project  into  the  uterine  cavity 
like  a  polypus.  For  the  inverted  portion  may  then 
provoke  contractions  which  increase  the  inversion, 
the  remainder  of  the  process  being  completed  by  the 
uterus  itself,  which,  so  to  speak,  swallows  the  in- 
dented portion.3 

Eclampsia  is  discussed  on  p.  68. 


1  Mtinchener  med.  Wochcnschrift,  1903,  p.  1462. 

*  Eden,  Midwifery,  p.  518. 

3  A  similar  process  is  sometimes  observed  when  a  submucous 
fibroid  projects  into  the  cavity  of  the  uterus.  Her- 
man and  Maxwell,  Diseases  of  Women,  p.  313. 


Chapter  IFUne 


CONSTITUTIONAL    DISEASES 

NDER  this  heading  will  be  described  some 
pernicious  circular  reactions  associated 
with  constitutional  diseases,  including  : 

I.     Obesity 
II.     Diabetes 
III.     Rickets 

I.     OBESITY 

Obesity  may  be  defined  as  the  condition  which 
results  from  long  continued  excess  in  the  amount  of 
food  consumed  over  that  katabolised  ;  it  becomes 
pathological  when  it  interferes  with  functional 
activity.  In  its  severe  form  obesity  tends  to  affect 
almost  every  function  of  the  body,  and,  owing  to 
what  Dyce  Duckworth  calls  the  "  Vicious  Circle  of 
malign  events,"  spells  disaster  to  its  victim.  For 
convenience  sake  disorders  of  the  cardio-vascular, 
the  respiratory,  the  digestive,  the  nervous,  the 
muscular  and  other  systems  will  be  dealt  with 
separately.1 

(a)    Cardio-Vascular    Disorders 

Cardio-vascular  disorders  result  from  the  extra 
strain  thrown  on  the  heart  and  the  blood-vessels, 
and  do  much  to  aggravate  the  primary  evil.  In 

^or  further  details  cf.  Obesity  and  its  Vicious  Circles,  by 

J.B.H.,  Practitioner,  1917,  II.,  p.  164. 
153 


154          IDidous  Cirde0  in  IDisease 

health  the  weight  of  the  cardiac  muscle  is  roughly 
in  proportion  to  the  weight  of  the  body.  In  cor- 
pulence, however,  this  proportion  is  disturbed  owing 
to  the  excess  of  adipose  tissue,  and  an  increased 
burden  is  imposed  on  the  myocardium.  In  order 
to  cope  with  this  extra  work  the  heart  undergoes 
a  beneficent  hypertrophy,  and  under  favourable 
circumstances  can  for  many  a  long  year  meet  the 
unusual  demands  made  upon  it.  Sooner  or  later, 
however,  the  hypertrophied  heart  tends  to  insuffi- 
ciency, the  time  when  such  insufficiency  manifests 
itself  depending  much  on  the  mode  of  life.  As  the 
cardiac  decompensation  progresses,  the  left  ventricle 
can  no  longer  drive  the  whole  of  its  contents  into 
the  aorta,  and  the  familiar  conditions  of  venous 
stasis  gradually  supervene.  These  unfortunately 
react  on  the  heart,  and  the  circular  reaction  of  heart 
failure  and  venous  stasis  is  established. 

The  result  is  a  serious  interference  with  the  activ- 
ities of  life.  Consciously  or  unconsciously  such 
tasks  as  cause  discomfort  are  avoided,  and  the 
muscular  work  accomplished  is  greatly  diminished. 
This  aggravates  the  primary  evil. 

Von    Noorden    writes  : 

"  Obesity  makes  great  demands  on  the  functional 
activities  of  the  heart  and  blood-vessels,  leading  to 
excessive  strain  and  weakness.  Conversely  every 
primary  cardio-vascular  disorder  cceteris  paribus  is  more 
dangerous  in  a  corpulent  than  in  a  thin  patient.  As 
a  result  of  this  injurious  Vicious  Circle  a  large  pro- 
portion of  corpulent  persons  sooner  or  later,  slowly 
or  rapidly,  present  signs  of  cardiac  failure  and  chronic 
blood-stasis  ;  in  the  long  run  most  stout  persons  die 
of  cardiac  failure."1 

Not  only  does  obesity  affect  the  heart  through  the 
increased  burden  imposed  ;  there  are  other  directly 

^ie  Fettsucht,  p.  30. 


Constitutional  Diseases 


155 


C,ard/ac 


(a)  OBESITY 


\Auscu/d/1 


30 


^ 


& 


ujnc\' 


(b)  DIABETES 


I 
I, 


Acci 


(c)  RICKETS 


plate  viii.— Circles  assodatefc  with 
Constitutional  Diseases. 


156  IDicious  Circles  in  Disease 

injurious  effects.  Fat  may  accumulate  in  the  heart 
in  two  ways.  In  the  first  place  there  may  be  exten- 
sive deposits  beneath  the  pericardium,  along  the 
auriculo- ventricular  and  inter- ventricular  sulci,  be- 
tween the  strands  of  muscle  and  even  beneath  the 
endocardium;  sometimes  the  weight  of  such  deposits 
exceeds  that  of  the  muscular  tissue  itself.  Fat  may 
also  be  deposited  in  the  mediastina  and  these  deposits 
combine  with  those  in  the  heart  itself  to  interfere 
with  the  cardiac  movements  and  aggravate  the 
myocardial  incompetence  of  the  obese.  In  the 
second  place  in  fatty  degeneration  fat  is  deposited 
as  fine  droplets  within  the  cardiac  muscle-cells. 
Hence  results  a  weakened  systole  and  a  lessened 
power  of  resistance.  These  injurious  effects  of 
obesity  are  of  course  intensified  when  fatty  infiltra- 
tion and  degeneration  co-exist.  The  associated 
symptoms  appear  earlier  as  well  as  in  greater  urgency 
and  tend  to  aggravate  the  obesity.  The  corpus 
adiposum  leads  to  the  cor  adiposum  and  vice  versa 

(plate  VHI.  a). 

Much  the  same  sequence  is  observed  when  some 
cardiac  disorder  supervenes  in  a  healthy  person. 
Such  disorder  obliges  the  cardiopath  to  renounce  all 
laborious  work,  thus  favouring  the  accumulation  of 
fat,  imposing  a  further  burden  on  the  heart  and 
increasing  the  risk  of  failure. 

Von  Noorden  writes  : 

"  Cardiovascular  disorders  lead  to  corpulence,  and 
the  corpulence  accelerates  the  cardiac  failure,  thus 
giving  rise  to  a  most  pernicious  Circle  (verderbliche 
Wechselwirkung) ." l 

Arterio-sclerosis  and  chronic  interstitial  nephritis 
are  frequent  complications  of  obesity,  and  in  time 
recoil  on  the  heart  and  eventually  on  the  obesity. 
The  sclerotic  changes  are  especially  prone  to  invade 

1  Die  Fettsucht,  p.  98. 


Constitutional  S>i0ea$e0  157 

and  narrow  the  coronary  arteries,  leading  to  ischsemia, 
degenerative  myocarditis  and  further  weakening 
of  the  coronary  circulation.1 

Warfield  writes  : 

"  The  primary  change  is  an  increased  tension  in  the 
arterioles  which  later  leads  to  thickening  of  the  coats 
of  the  vessels  and  to  the  other  consequences  of  arterial 
disease.  A  Vicious  Circle  is  thus  established  which 
has  a  tendency  to  become  progressively  worse."2 

Such  cardiac  insufficiency  greatly  curtails  all 
forms  of  physical  exercise  with  the  result  of  increased 
corpulence.  The  interference  with  the  coronary  cir- 
culation due  to  corpulence  may  in  fact  create  two 
concurrent  Circles,  one  of  short  (A),  the  other  of 
longer  circuit  (B)  : 

A. 

Impaired    coronary    Malnutrition    of 

circulation  *    myocardium 


Feeble    systole 

B. 

Impaired  coronary    » — »•  Cardiac    insufficiency 
circulation  », 

i  ' 

Increased  corpulence     « — **    Lessened   physical 

activity 

Obese  persons  frequently  suffer  from  anaemia, 
due  to  the  lessened  amount  of  haemoglobin  associ- 
ated with  decreased  absorption  of  oxygen  and  a 

1  Kisch,  Die  Fettleibigkeit,  pp.  116,  145. 
2Arterio-sclerosis,  pp.  87,  113,  163. 


158         IDtctoug  Circles  in  Bisease 

slowing  of  the  oxidation  processes.  The  resulting 
symptoms  are  shortness  of  breath,  giddiness,  tinnitus, 
palpitations  and  a  tendency  to  temporary  anasarca. 
All  these  troubles  tend  to  indolence  and  so  favour 
corpulence. 

(b)    Respiratory  Disorders 

Various  respiratory  disorders  result  from,  and  in 
turn  promote,  obesity.  For  example,  the  thoracic 
cavity  may  be  encroached  upon  by  fatty  cushions 
in  the  mediastina  and  by  the  fatty  enlarged  heart  ; 
the  respiratory  muscles  and  ribs  may  be  overweighted 
with  fat  and  unable  to  expand  the  thoracic  walls 
efficiently;  the  diaphragmatic  pump  may  be  unequal 
to  the  task  of  forcing  down  the  fatty  viscera  in 
the  abdomen,  which  is  itself  encroached  upon  by 
extensive  and  unyielding  accumulations  of  fat. 
Thus  both  the  respiratory  capacity  of  the  chest 
and  the  respiratory  movements  of  the  lungs  are 
restricted;  the  patient  quickly  becomes  dyspnoeic 
on  slight  provocation.  These  conditions  tend  to 
shallow  breathing  movements,  and  the  more  super- 
ficial the  respiration,  the  less  the  negative  pressure 
in  the  chest,  and  the  less  the  assistance  given  to  the 
return  of  venous  blood  to  the  heart  and  to  the 
pulmonary  circulation. 

The  shallower  the  respiratory  movements  the 
slower  the  rate  of  oxidation  ;  the  fat-forming  sub- 
stances are  less  perfectly  burned  up  and  are  more 
largely  deposited  as  fat,  all  these  conditions  being 
closely  linked  in  reciprocal  correlations. 

Increase  of  obesity  is  also  favoured  by  the  im- 
paired respiration  leading  to  hypertrophy  and  dila- 
tation of  the  right  heart  with  their  influence  on 
venous  stasis  and  impeded  oxygenation. 

Campbell  writes  : 

"  Since  obesity   restricts  both  costal  and  diaphrag- 
matic movement,  and   at  the  same  time  curtails  the 


Constitutional  Diseases  159 

respiratory  area,  it  necessarily  impedes  the  circulation, 
causing  the  blood  to  flow  with  increased  difficulty 
through  the  lungs.  Hence  the  tendency  to  hypertrophy 
and  dilatation  of  the  right  heart  in  the  obese,  and  for 
the  blood  to  be  dammed  back  upon  the  great  veins. 
The  circulation  being  sluggish  and  the  respiratory 
action  curtailed,  the  further  formation  of  fat  is  favoured. 
Thus  fat  begets  fat."1 

Feeble  respiratory  movements  from  these  or 
other  causes  lead  to  defective  nutrition  of  the  lungs, 
since  such  nutrition  largely  depends  on  adequate 
movements  ;  impaired  pulmonary  nutrition  in  its 
turn  tends  to  feeble  movements. 

Another  consequence  of  impaired  movement  and 
imperfect  aeration  is  increased  liability  to  bronchial 
catarrh,  which  tends  to  become  chronic  and  further 
to  impede  oxygenation.  The  associated  cough  is 
less  effective  in  expelling  pulmonary  and  bronchial 
secretions.  Chronic  bronchitis  and  emphysema  are 
frequent  and  self -aggravating  sequelae.  Corpulent 
persons  are  bad  breathers. 

These  pulmonary  disorders  curtail  physical  activ- 
ity. Every  exertion  that  embarrasses  breathing  is 
gradually  abandoned  and  such  diminished  exercise 
in  its  turn  favours  corpulence. 

(c)  Digestive  Disorders 

We  may  deal  in  order  with  the  stomach,  the  liver 
and  the  bowels. 

In  health  an  automatic  self-regulating  mechanism 
of  great  accuracy  governs  the  daily  imports  and 
exports  of  the  body.  This  mechanism  leads  the 
individual  unconsciously  to  adopt  a  maintenance 
diet,  i.e.  the  quantity  and  kind  of  food  on  which 
imports  and  exports  are  in  equilibrium,  and  on 
which  an  average  weight  is  maintained. 

1  Respiratory  Exercises  in  the  Treatment  of  Disease,  p.  137. 


i6o          \Diciou0  Circles  in  Disease 


Under  various  conditions,  however,  this  mechan- 
ism is  thrown  out  of  gear  ;  appetite  ceases  to  be  a 
trustworthy  guide,  and  more  food  is  consumed  than 
is  required  for  the  nutrition  of  the  body.1 

In  obesity  such  a  perverted  appetite  often  leads 
to  an  excessive  consumption  of  food.  In  fact  bou- 
limia  may  accompany  a  strong  conviction  that 
the  appetite  is  in  no  way  abnormal. 

Again  corpulence  often  creates  a  sense  of  exhaus- 
tion and  the  sufferer  stuffs  himself  with  food  in  the 
hope  of  obtaining  relief.  The  result  is  in  many 
cases  gastrectasis  with  hunger-pain,  followed  by  a 
ravenous  appetite  and  further  dilatation  and  obesity. 
This  sense  of  exhaustion  frequently  leads  obese 
persons  to  resort  to  alcoholic  drinks,  a  remedy  which 
is  particularly  insidious  in  such  persons  since  the 
drinks  are  generally  added  to  an  already  ample 
diet.  Moreover  alcohol  promotes  obesity  through 
its  ready  oxidation  ;  it  is  a  source  of  energy  and 
a  sparer  of  fat.  According  to  von  Noorden  one 
grm.  of  alcohol,  with  a  physiological  value  of  7 
calories,  saves  the  body  -75  grm.  of  fat  or  1-7  grm.  of 
carbohydrate.  When  it  is  remembered  how  many 
people  take  50  grm.  of  alcohol  a  day  and  even  much 
more,  the  important  role  played  by  alcohol  in  pro- 
moting obesity  is  evident.2  Corpulence  and  alcohol- 
ism reciprocally  favour  each  other. 

Craving  for  food  is  also  largely  dependent  on 
habit.  If  the  stomach  is  accustomed  to  a  high 
degree  of  repletion  a  meal  does  not  yield  full  satis- 

1  Obese  persons  need  relatively  less  food  than  others.     About 

26-36  calories  per  kilo,  of  body-weight  suffice,  in- 
stead of  the  normal  34-45  calories.  This  is  due  to 
the  relatively  small  surface  of  their  body,  to  the 
smaller  loss  of  heat,  to  the  fact  that  fat  does  not 
consume  energy,  and  to  the  less  amount  of  exercise 
usually  taken. 

2  Von  Noorden,  Die  Fettsucht,  p.  28, 


Constitutional  dieeaeea  161 

faction  until  the  customary  distention  has  been 
reached.  Heavy  meals  tend  to  become  habitual. 
As  a  result  of  boulimia  some  obese  persons  become 
plethoric,  and  not  anaemic  as  occurs  under  other 
circumstances.  Their  blood  is  rich  both  in  red 
cells  and  in  haemoglobin;  their  circulatory  and  di- 
gestive systems  are  usually  active.  These  con- 
ditions aid  and  abet  each  other.  For  some  years 
such  persons  may  enjoy  robust  health  and  unusual 
powers  of  work.  There  is,  however,  always  a  ten- 
dency to  sclerotic  changes  and  eventually  to  cardiac 
failure. 

Martinet  describes  the  correlations  : 

"  The  over-nutrition  leads  to  a  state  of  plethora  with 

its  concomitants,  and  is  associated  with  an  abnormal 

activity  of  the  vascular  aud  renal  systems.     The  active 
.    circulation  excites   more   copious   digestive   secretions 

and  these  again  maintain  the  over-nutrition.    A  Vicious 

Circle  is  thus  established."1 

The  viscera  are  apt  to  become  the  seat  of  fatty 
deposits  in  obese  persons  ;  such  a  condition  tends 
to  indolence  and  favours  the  increase  of  obesity. 
An  excellent  illustration  of  this  is  presented  by  the 
liver  which  may  become  greatly  enlarged  and  weigh 
many  pounds  more  than  the  healthy  organ.  The 
proportion  of  the  fat  may  rise  from  the  normal  of 
1-4  p.c.  of  the  hepatic  tissue  to  30  or  even  80  p.c.2 
Moreover  as  soon  as  the  obesity  has  led  to  venous 
stasis,  a  fresh  factor  is  introduced  which  affects  the 
whole  portal  area,  leading  to  increased  weight  of  the 
body,  impaired  activity  and  further  corpulence. 

Constipation  is  another  complication  resulting 
from,  and  in  turn  favouring,  obesity.  Peristaltic 
movements  are  impeded,  the  abdominal  muscles 
are  weakened  and  physical  activity  is  lessened. 

^ressions  Arterielles  et  Viscosite  Sanguine,  p.  226. 

2  Bouchard  and  Brissaud,  Traite  de  Medecine,  I.,  p.  424. 


162        iDictoiis  Circles  in  Disease 

The  progress  of  the  intestinal  contents  is  slowed, 

and  a  larger  proportion  of  the   ingesta  is  absorbed. 

All  these  factors  aggravate  obesity.1 

Krehl  thus  sums  up  the  cumulative  effect  of  the 

various  conditions  : 

"  These  causes,  singly  or  together,  are  responsible 
for  most  cases  of  obesity.  It  is  merely  a  problem  in 
arithmetic.  A  certain  amount  of  energy  is  taken  in 
the  form  of  food,  a  certain  amount  is  lost  as  heat  and 
work,  and  the  remainder  is  stored  up  in  the  body  mainly 
as  fat.  As  soon  as  the  accumulation  of  fat  begins  to 
deter  the  patient  from  taking  exercise,  a  Vicious  Circle 
is  established  and  he  tends  to  increase  in  weight  more 
and  more."2 

(d)   Nervous   Disorders 

Corpulence  is  frequently  associated  with  a  slug- 
gish nervous  system,  although  this  relation  is  by  no 
means  constant  ;  many  obese  persons  are  mentally 
and  physically  active  and  get  through  a  large 
amount  of  work. 

Von  Noorden  writes  : 

"  Nervous  and  physical  indolence  often  long  precede 
corpulence,  but  they  favour  its  onset  and  accelerate 
its  progress.  On  the  other  hand  the  corpulence  in  its 
turn  acts  as  an  additional  cause  for  indolence  and 
inactivity."3 

In  other  cases  corpulence  is  independent  both  of 
excess  of  diet  and  of  deficiency  of  exercise,  and 

1H.  Lohrisch  found  that  in  a  diet  with  an  energy  value  of 
7,000  calories  about  270  calories  are  lost  in  the 
faeces  of  a  person  with  regular  action  of  the  bowels, 
while  only  170  calories  are  lost  in  a  constipated 
person.  Deutsch.  Archiv  f.  klin.  Medizin,  LXXIX. 
(1904),  p.  383.  Cf.  also  Medizinische  Klinik,  V. 
(1909),  p.  439- 

2  Basis  of  Symptoms,  p.  315. 

3  Die  Fettsucht,  p.  79. 


(tonstitutional  Diseaaee  163 

results  from  retarded  katabolism  due  to  such  con- 
ditions as  hypothyroidism  and  hypopituitarism  (en- 
dogenous obesity).  The  correlations  are  obscure, 
but  it  seems  probable  that  hypothyroidism  and 
hypopituitarism,  possibly  associated  with  some  form 
of  toxaemia,  may  in  turn  react  on  nervous  functions, 
thus  perpetuating  the  disorder. 

Many  obese  persons  sleep  abnormally  long,  even 
as  much  as  ten  or  twelve  hours  a  day.  This  excess- 
ive somnolence  may  be  due  to  a  chronic  carbonaemia 
dependent  on  cardiac  insufficiency,  diminished  respir- 
atory capacity  or  defective  diaphragmatic  activity. 
Whatever  the  cause,  such  somnolence  favours  cor- 
pulence since  only  about  half  as  many  calories  are 
expended  during  sleep  as  during  work.  L,6bisch 
estimates  that  an  obese  person  who,  without  other- 
wise changing  his  diet  or  mode  of  life,  increases  his 
hours  of  sleep  from  seven  to  eight  adds  1043*9  grm. 
of  fat  during  the  year.  From  8  '2-8  -5  grm.  less 
CO2  per  hour  is  excreted  by  a  sleeping  than  by  a 
waking  person.1 

Other  complications  are  superadded  when  cor- 
pulence is  complicated  by  cardiac  insufficiency, 
since  the  voluntary  effort  required  to  keep  up 
active  habits  involves  heavy  drafts  on  the  reserve 
energy.  The  necessary  strength  of  will  is  usually 
either  lacking,  or  is  exerted  at  such  cost  that  exhaus- 
tion supervenes  before  enough  muscular  work  has 
been  performed  to  influence  metabolism.  The  greater 
the  sense  of  weakness  the  greater  the  effort  required 
and  the  less  can  be  accomplished. 

Various  other  nervous  symptoms  may  be  present, 
such  as  giddiness,  tinnitus  and  muscse  volitantes, 
all  of  which  tend  to  lower  self-confidence  and  impair 
physical  activity.  They  are  probably  dependent 
on  deficient  blood-supply  to  the  nerve  centres. 


,  Die  Fettleibigkeit,  p.  17. 


164          Dicious  Circles  in  2>teea$e 

(e)  Cutaneous  and  Sexual  Disorders 
Both  the  cutaneous  and  sexual  systems  are  affect- 
ed by  corpulence  and  the  resulting  disorders  may 
aggravate  the  primary  trouble.  For  instance,  de- 
posits of  subcutaneous  fat  diminish  the  amount  of 
heat  given  off  by  radiation  and  conduction,  and 
conserve  the  body  heat.  The  result  is  a  lowered 
metabolism  of  heat-producing  materials  and  a 
tendency  to  increased  corpulence.  A  further  effect 
is  sluggishness  of  the  heat-regulating  mechanism. 
The  superficial  area  of  the  body  is  smaller  in  a 
corpulent  than  in  a  spare  person  in  proportion  to  the 
weight  ;  this  tends  to  check  the  loss  of  heat,  while 
pyrexia  is  more  obstinate  and  involves  greater  peril. 
On  the  other  hand  under  the  influence  of  muscular 
exercise  or  of  emotion,  perspiration  and  evaporation 
are  more  active  in  obesity.  Many  corpulent  persons 
are  like  Falstaff  "  subject  to  heat  as  butter  ....  in 
continual  dissolution  and  thaw."1  Unfortunately, 
however,  such  profuse  perspiration  leads  to  much 
discomfort  and  diminishes  inclination  for  exercise, 
thus  tending  to  increased  corpulence  and  hyper- 
hidrosis.2 

Hewlett  writes  : 

"  The  outlook  for  a  spontaneous  cure  of  obesity  is 
not  good.  As  obesity  increases  the  avoidance  of  exer- 
cise becomes  more  and  more  necessary,  on  account  of 
the  increasing  tendency  to  sweating  and  the  shortness 
of  breath  on  exertion.  A  Vicious  Circle  is  thus  estab- 
lished, for  the  increasing  weight  limits  the  exercise,  and 
the  limited  exercise  tends  to  increase  the  weight."3 

This  liability  to  profuse  perspiration  is  specially 
marked  in  moist  warm  climates  such  as  are  often 

1  Merry  Wives  of  Windsor,  III.,  v. 

2  Von  Noorden  gives  a  table  shewing  the  great  difference 

in  the   amount   of  perspiration  in  thin   and  stout 
persons.     Die  Fettsucht,  p.   114. 
3Musser  and  Kelly,  Practical  Treatment,  III.,  p.  52. 


Constitutional  Diseases  165 

found  in  the  tropics,  and  accounts  for  the  inability 
of  stout  persons  to  undertake  physical  exercise. 
At  times  the  excessive  moisture  causes  maceration 
of  the  skin  of  the  soles  and  tenderness  of  the  feet. 
Walking  becomes  painful  and  this  favours  progressive 
obesity. 

Fat  women  sometimes  suffer  from  vulvitis  and 
excoriations  of  the  nymphse  which  may  be  associated 
with  difficulty  in  the  removal  of  smegma.  Such 
vulvitis  may  cause  exercise  to  be  restricted  within 
the  narrowest  limits. 

The  excretion  of  fat  via  the  sebaceous  glands  is  less 
active  in  corpulent  than  in  normal  persons,  if  some 
observations  by  L,eubuscher  are  to  be  relied  upon. 
This  factor  must  tend  to  perpetuate  obesity.1 

The  sexual  appetite  is  distinctly  lowered  in  obese 
persons  according  to  Dyce  Duckworth.2  On  the 
other  hand  inertness  of  the  sexual  organs  may  in  its 
turn  favour  the  deposition  of  fat  ;  this  correlation, 
however,  is  by  no  means  a  constant  one. 

(f)    Muscular    Disorders 

Important  correlations  connect  corpulence  with 
the  muscular  system. 
Adami  writes  : 

"  The  accumulation  of  fat  in  the  tissues,  when  ex- 
treme, hinders  activity,  and,  doing  this,  brings  about 
diminished  oxidation,  thus  setting  up  a  Vicious  Circle."3 

During  the  earlier  half  of  life  increase  of  fat  appears 
usually  to  lead  to  an  associated  growth  of  muscle 
fibre.  But  this  beneficent  relation  ceases  as  the 
years  roll  by,  and  muscular  development  no  longer 
keeps  pace  with  advancing  adiposity.  On  the 
contrary  the  obese  person  needs  to  expend  greater 


'XVII.  Kongress  f.  innere  Medizin  (1899),  p.  457. 
2Allbutt  and  Rolleston,  System  of  Medicine,  IV.,  p.  493. 
8  Principles  of  Pathology,  I.,  p.  379. 


166          iDicious  Circles  in  Disease 

effort  in  the  performance  of  physical  work,  conse- 
quently he  tires  more  easily  and  seeks  to  avoid 
exertion.  The  more  he  weighs  the  less  he  exercises  ; 
the  less  he  exercises  the  more  he  weighs  (JMatC  VIII. a). 
Gilford  describes  the  correlation  : 

"  Muscular  correlation  is  sometimes  very  defective, 
especially  when  fatness  sets  in  after  middle  age,  when 
the  muscular  system  is  no  longer  able  to  rise  to  the 
occasion.  A  Vicious  Circle  is  often  established.  The 
tired  muscles  insist  upon  rest,  but  more  rest  means 
more  fat,  and  so  the  inadequacy  of  the  muscles  is  still 
further  increased."1 

As  a  rule  the  muscular  system,  both  voluntary  and 
involuntary,  is  under-developed  and  weak  in  stout 
persons,  who  too  often  neglect  to  take  the  exercise 
which  is  so  necessary  if  the  tendency  to  corpulence 
is  to  be  checked. 

Von  Noorden  writes  : 

"  As  a  rule  stout  persons  do  not  exercise  their  muscles 
sufficiently  to  bring  those  muscles  and  the  myocardium 
into  relation  with  the  demands  made  on  them  by  the 
increased  weight  of  their  body.  Even  if  they  try  to 
do  so,  their  weight  frequently  increases  so  rapidly  that 
the  adaptation  of  the  voluntary  muscles  and  still  less 
of  the  cardiac  muscle  cannot  keep  pace  with  it.  More- 
over in  the  case  of  those  numerous  persons  whose  cardio- 
vascular system  is'naturally  somewhat  under-developed, 
the  progressive  adaptation  of  the  heart  ceases  at  an 
early  age.  Here  then  is  a  form  of  circulus  vitiosus. 
Persons  with  a  feeble  circulatory  system  give  up  active 
habits  at  an  early  age  (i.e.  soon  after  the  close  of  adoles- 
cence) and  pave  the  way  for  obesity  (exogenous  obesity 
from  inactivity).  The  further  this  advances  (many 
conditions  may  contribute),  the  greater  becomes  the 
maladjustment  between  the  vigour  of  the  heart  and 
the  weight  of  their  body."2 

Disorders  of  Post-Natal  Growth  and  Development,  p.  515. 
This  Circle  is  illustrated  by  J .  S.  Kellett  Smith.  The 
Cure  of  Obesity  and  Obese  Heart,  p.  64. 

2  Die  Fettsucht,  p.  85. 


Constitutional  SHaeaaee  167 

Even  more  serious  is  this  condition  in  elderly 
persons  whose  recuperative  powers  are  greatly  re- 
duced. 

Von  Koranyi  writes  : 

"  When  in  elderly  persons  changes  and  disorders 
of  the  organs  of  locomotion,  of  circulation,  of  respira- 
tion and  of  the  nervous  system  lead  to  diminished 
exercise  and  consequent  obesity,  a  Vicious  Circle  is 
established.  For  such  increase  in  weight  leads  in 
turn  to  further  restriction,  loss  of  power  of  locomotion, 
and  to  progressive  disorder  of  the  circulation  and  re- 
spiration."1 

In  advanced  cases  of  obesity  the  unusual  efforts 
required  by  the  lumbar  and  sacral  muscles  in  order 
to  maintain  the  erect  posture  induce  persistent 
back-ache  which  interferes  much  with  locomotion 
and  leads  to  an  indolent  life  on  the  sofa.  Some- 
what allied  to  these  incapacitating  conditions  are 
sprains,  muscular  stiffness  and  flat  foot.  Flat  foot 
frequently  results  from,  and  aggravates,  obesity. 
There  is  also  "  the  obese  patient  with  enlarged, 
grating  and  painful  knee  joints,  which  limit  activity 
and  so  help  to  complete  a  Vicious  Circle."2 

II.     DIABETES 

Diabetes  may  be  complicated  by  several  self- 
aggravating  conditions. 

In  some  forms  of  the  disease  the  ingestion  of 
sugar  diminishes  the  power  of  the  diabetic  to  split 
up  the  molecule  of  glucose.  Thus  the  consumption 
of  a  definite  quantity  of  sugar  may  lead  to  the 
elimination  in  the  urine  of  a  larger  quantity  than  has 
been  consumed.  In  other  words  the  increased 
glycsemia  reduces  the  power  of  burning  up  sugar. 

Allen  has  proposed  to  use  this  observation  as  a 
means  of  distinguishing  diabetes  from  glycosuria, 
and  has  formulated  the  following  law  :  "In  normal 

1Schwalbe,  Lehrbuch  der  Greisenkrankheiten,  p.  719. 
2Kellett  Smith,  The  Cure  of  Obesity  and  Obese  Heart,  p.  62. 


168          IDicious  Circles  in  Disease 

individuals  the  more  sugar  is  given  the  more  is 
utilised,  while  the  reverse  is  true  in  diabetes." 

Another  circular  reaction  may  be  established  as  a 
result  of  inadequate  nutrition  in  cases  of  severe 
glycaemia.  Metabolism  may  indeed  be  so  greatly 
disturbed  that  the  administration  of  carbo-hydrates 
is  required  in  order  to  prevent  rapid  inanition. 
The  carbo-hydrates  in  their  turn  intensify  the  glycse- 
mia  and  increase  the  inanition  which  requires  further 
administration  of  carbo-hydrates  (JMatC  VIII.  b). 
In  these  cases  the  amount  of  carbo-hydrate  that  can 
be  utilised  must  be  carefully  ascertained  so  that 
the  patient  receives  this  amount  and  no  more,  other- 
wise the  glycosuria  may  actually  be  aggravated. 
Pick  and  Hecht  thus  allude  to  this  process  : 

"  Strict  individualisation  and  constant  regulation  of 
the  diet,  with  control  of  the  general  symptoms,  and 
exact  quantitative  determination  of  the  urinary  con- 
stituents, often  permit  us  to  avoid  the  dangers  of  this 
Vicious  Circle."1 

Many  physiologists  hold  that  there  is  a  constant 
tendency  of  the  liver  to  convert  glycogen  into  sugar 
through  the  action  of  a  diastatic  or  glycogenolytic 
ferment,  which  tendency  is  held  in  check  by  an 
inhibitory  mechanism  controlled  from  a  centre  in 
the  floor  of  the  fourth  ventricle.  If  this  is  so,  it 
seems  not  unlikely  the  nutritive  disorders  resulting 
from  chronic  diabetes  may  weaken  this  inhibitory 
mechanism  and  perpetuate  the  glycosuria.  On  this 
theory  the  gradual  increase  of  diabetes  would  also 
be  explained. 

Again  in  cases  of  chronic  hyperglycsemia  the 
kidneys  lose  somewhat  of  their  fine  sensitiveness  to 
increase  in  the  blood  sugar,  and  the  degree  of 
hyperglycsemia  tends  to  rise  progressively. 

III.     RICKETS 
Rickets  is  believed  to  be  due  to  defective  and 

1  Clinical  Symptomatology,  p.  592. 


Constitutional  SDtgeaseg 169 

perverted  nutrition,  mainly  caused  by  an  insufficient 
supply  of  animal  fat  and  of  earthy  salts  in  the  form 
of  phosphates,  combined  in  many  cases  with  a 
shortage  of  animal  protein.  The  result  is  a  general 
disorder  of  a  large  number  of  the  tissues  and  struc- 
tures of  the  body,  including  the  nervous,  respiratory, 
digestive,  haemopoietic  and  muscular  systems.  These 
disorders  acting  cumulatively  aggravate  and  perpet- 
uate the  processes  of  malnutrition.  The  sequence  of 
events  doubtless  varies  under  different  circumstances. 
At  times  the  digestive  system  is  chiefly  disturbed, 
leading  to  fermentation,  flatulence  and  catarrh  of  the 
digestive  tract,  which  seriously  affect  assimilation 
and  intensify  the  primary  disorder  (JMatC  VIII.  c). 

In  other  cases  the  liver  and  nervous  system  bear 
the  brunt  of  the  disorder. 
Pritchard  writes  : 

"  The  pathogenesis  of  the  disease  thus  defined  must 
be  regarded  as  a  Vicious  Cycle  of  events  in  which  each 
individual  link  in  the  chain  acts  and  reacts  on  the 
others.  In  describing  this  Vicious  Cycle  it  is  difficult 
to  know  at  what  point  to  begin  ;  indeed,  in  the  pro- 
duction of  rickets  there  is  no  starting-point ;  the 
disease  may  start  in  a  variety  of  ways. 

The  Vicious  Cycle  may  be  briefly  described  as  consist- 
ing of  an  inefficient  liver  associated  with  a  disturbed  cen- 
tral nervous  system  acting  and  reacting  on  one  another. 
These  are  the  two  pathological  pivots  on  which, 
according  to  my  view,  the  symptoms  mainly  hinge. 
The  liver  may  be  primarily  damaged  by  faulty 
methods  of  feeding,  from  abuse  of  its  functions,  or  from 
overwork,  or  it  may  be  inherently  or  congenitally  weak. 
As  a  rule  there  is  first  indigestion,  with  the  formation  of 
toxic  products  of  indigestion,  then  efforts  on  the  part 
of  the  liver  to  oxidize  or  destroy  these  products,  then 
collapse  or  failure  of  liver  function  with  the  escape  of 
these  unoxidized  products  into  the  general  circulation, 
and  finally  poisoning  of  the  nervous  system  itself. 

Poisoning  of  the  nervous  system,  from  whatever  cause 
induced,  not  only  intensifies  the  liver  inefficiency  by 
interfering  with  its  nervous  mechanism,  but  it  also 


170          Dicious  Circles  in  disease 

leads  to  incapacity  of  other  furnaces  in  the  body,  and 
herein  lies  the  essence  of  the  Vicious  Cycle  of  events."1 
The  respiratory  mechanism  is  especially  involved 
in  some  forms  of  rickets.  This  mechanism  is  always 
functionally  weak,  and  where  the  ribs  are  much 
deformed  a  line  of  depression  may  be  seen  running 
transversely  across  the  chest  from  the  lower  end  of 
the  sternum,  and  corresponding  roughly  to  the  line 
of  attachment  of  the  diaphragm.  Even  in  ordinary 
inspiration  and  still  more  when  there  is  any  obstruc- 
tion to  breathing  the  chest  may  be  drawn  in  during 
inspiration  along  this  line,  thus  interfering  with 
oxygenation. 

Beneath  this  line  patches  of  collapsed  lung  are 
often  found,  and  such  collapse  by  producing  dys- 
pnoea may  lead  to  further  drawing  in  of  the  ribs 
and  thus  aggravate  the  collapse.  This  sequence  is 
frequently  observed  in  the  bronchitis  which  is  so 
frequent  a  complication  of  rickets  (plate  VIII.  c). 
Still  writes  : 

"  Bronchitis    is    very  frequent  in  rachitic  children 

and  this  tendency  is  favoured,  in  severe  cases,  by  the 

softness  of  the  ribs  and  the  weakness  of  the  respiratory 

muscles.     There    is,    in    fact,    a    Vicious    Circle.     For 

mechanical  reasons  the  lung  is  very  imperfectly  filled 

with  air  and  the  collapse  thus  induced  favours  the 

occurrence  of  bronchitis  and  hence  further  collapse."2 

The  thoracic  deformity  of  rickets  appears  at  times 

to  be  not  merely  a  result  of  softening,  but  also  a  cause 

of  further  softening  owing  to  the  continued  irritation. 

McKenzie  writes  : 

"  It  is  a  well-recognised  fact  that  the  rickety  deform- 
ity manifests  itself  most  in  those  parts  exposed  to 
mechanical  strain.  The  mechanical  strain  produces 
a  deformity  in  the  first  place  and  in  the  second  excites 
further  rachitic  softening  by  its  irritation,  thus  pro- 
ducing for  a  time  a  Vicious  Cycle  of  events."3 

xThe  Infant,  p.  234. 

2  Osier  and  Macrae,  System  of  Medicine,  I.,  p.  884. 

3  British  Med.  /.,  1911,  I.,  p.  930. 


Chapter 


THE   EYES    AND    EYE-LIDS 

ISORDERS  associated  with  the  eyes  may 
conveniently  be  discussed  under  the 
following  headings,  although  the  classi- 
fication cannot  always  be  strictly  adhered 

to  : 

I.  The   Eyes 

II.  The    Eye-lids 

III.  Errors    of    Refraction 

IV.  Neuroses 

I.     THE   EYES 

Conjunctivitis.  Conjunctivitis  gives  rise  to 
various  secondary  conditions  which  perpetuate  the 
conjunctivitis.  One  of  the  commonest  of  these 
is  blepharospasm  which  may  accompany  any  form 
of  conjunctival  inflammation.  By  its  means  irri- 
tant secretions  are  pent  up  and  their  retention 
perpetuates  the  irritation. 

Perhaps  the  severest  form  of  blepharospasm  is 
met  with  in  the  phlyctenular  conjunctivitis  of 
children.  The  lids  are  kept  tightly  closed  for  hours 
together,  thus  retaining  the  discharges  in  prolonged 
contact  with  the  inflamed  surfaces.  Moreover  the 
exclusion  of  light  renders  the  retina  more  and  more 
sensitive,  and  this  factor  also  tends  to  intensify 
the  blepharospasm. 

In  some  forms  of  conjunctivitis  the  discharges  are 
highly  virulent,  as  for  example  in  ophthalmia 
neonatorum  and  gonorrhceal  ophthalmia.  The  irri- 
tating secretions  may  also  be  confined  under  consider- 

171 


172          IDicious  Circles  in  IDisease 


able    pressure    and    such    pressure    increases    their 
deleterious  action. 

Blepharospasm  may  also  be  associated  with 
entropion  which  causes  the  inturned  eye-lashes  to 
irritate  the  inflamed  conjunctiva  and  thus  to  per- 
petuate the  ophthalmia.  Such  a  condition  is  not 
uncommonly  seen  in  children  when  a  foreign  body 
has  lodged  in  the  eye. 

Other  reciprocally  acting  conditions  may  com- 
plicate granular  conjunctivitis  or  trachoma.  The 
granulations  are  stated  to  be  both  cause  and  effect  of 
the  inflammation,  each  disorder  contributing  to  the 
other. 

Burnett  writes  : 

"  There  has  always  been  a  question  as  to  whether 
the  granulations  are  the  cause  or  the  result  of  the 
inflammation.  From  the  fact,  however,  that  they 
have  been  found  in  eyes  which  have  not  been  inflamed, 
it  would  appear  more  likely  that  the  inflammation  is 
not  the  first  step  in  the  process,  though  undoubtedly 
the  inflammation,  when  it  is  once  set  up,  facilitates  its 
progress  and  encourages  new  deposits,  and  thus  a 
Vicious  Circle  is  completed."  l 

Conjunctivitis  frequently  depreciates  the  general 
health  and  thus  delays  recovery .  For  example,  phlye- 
tenular  conjunctivitis  is  prevalent  in  ill-nourished 
strumous  children  who  in  order  to  escape  all  light 
remain  indoors  in  darkened  rooms,  and  bury  their 
faces  in  cushions  or  under  shawls.  The  seclusion 
from  light,  air  and  exercise  lowers  the  already 
depressed  nutrition  and  aggravates  the  disease. 
Again  gonorrhoeal  conjunctivitis  is  often  associated 
with  extreme  physical  and  mental  depression  caused 
by  remorse  and  the  anticipation  of  blindness.  Such 
fears  naturally  lower  vitality  and  retard  processes  of 
repair. 

Morris  and  Oliver,  System  of  Diseases  of  the  Eye,  III., 
p.  209. 


173 


(a)  CORNEAL  ULCER 


(b)  GLAUCOMA 


(c)  ECTROPION 


(e)  MYOPIA 


(d)  ENTROPION 


(f)  ASTHENOPIA 


plate  ix.— Circles  aesociateb  wttb 
tbe 


174          tDicioue  Ctrclee  in  Disease 

Keratitis.  Some  of  the  circular  reactions  de- 
scribed in  connection  with  conjunctivitis  apply  to 
keratitis.  In  fact  conjunctivitis  and  keratitis  are 
intimately  associated,  and  the  influence  of  blepharo- 
spasm  in  causing  retention  of  secretions  is  equally 
injurious  in  both  disorders. 

Trichiasis  due  to  entropion  is  especially  dangerous 
when  there  is  ulceration  of  the  corneal  surface,  since 
the  usual  epithelial  protection  is  lost. 

Lawson  writes  : 

"  The  corneal  inflammation  causes  great  pain  with 
photophobia  and  lachrymation,  owing  to  which  the 
patient  keeps  his  eyes  convulsively  closed  (blepharo- 
spasm),  and  by  so  doing  causes  a  still  greater  approxi- 
mation of  the  incurved  lashes  to  the  cornea,  and 
establishes  a  Vicious  Circle.  If  the  condition  is  not 
relieved  by  artificial  means  matters  will  go  from  bad 
to  worse,  and  in  time  the  sight  will  be  completely 
destroyed."  1 

Another  troublesome  complication  of  corneal  ulcer 
is  incessant  blinking,  which  causes  the  upper  lid  to 
rub  against  and  irritate  the  inflamed  surface  and  thus 
hinders  repair  (plate  IX.  a). 
L,awson  writes  : 

"  The  movement  of  the  upper  lid,  by  rubbing  against 
and  irritating  the  ulcerated  surface,  increases  the  pain 
and  photophobia,  and  in  this  way  keeps  up  a  Vicious 
Circle,  which  is  arrested  by  a  light  bandage."2 

In  some  cases  of  chronic  keratitis  the  corneal 
tissues  may  be  so  softened  and  thinned  as  to  be 
unable  to  resist  the  intra-ocular  pressure.  A  staphy- 
loma  corneae  then  results,  with  progressive  bulging 
which  causes  further  attenuation  and  further  bulg- 
ing.3 A  similar  sequence  is  sometimes  associated 

Injuries  and  Diseases  of  the  Eye,  p.  459. 

*L.c.,  p.  145. 

3  Roemer,  Text-Book  of  Ophthalmology,  p.  532, 


anfr  ^e^Itbg  175 


with  keratoconus  and  scleral  ectasise.  These  con- 
ditions will  be  further  alluded  to  in  connection  with 
secondary  glaucoma. 

Corneal  ulcer  is  another  example  of  a  chronic 
disease  whose  duration  is  prolonged  by  a  depreci- 
ation of  vitality.  Such  depreciation  may  keep  up 
the  local  disorder  and  vice  versa. 

Iritis.  A  striking  feature  of  iritis  is  its  liability 
to  establish  a  locus  minoris  resistentice  with  a  strong 
tendency  to  relapse.  This  proclivity  was  formerly 
attributed  to  irritation  caused  by  synechiae.  But 
the  modern  view  is  that  recurrence  results  from  the 
persistence  of  some  such  constitutional  dyscrasia  as 
may  be  caused  by  syphilis  or  rheumatism,  and  that 
the  damaged  iris  constitutes  a  susceptible  focus. 
With  each  attack  a  slighter  provocation  suffices  for 
recrudescence. 

Glaucoma.  Glaucoma  is  frequently  complicated 
by  injurious  circular  reactions  (JMatC  IX.  b).  In 
the  words  of  Priestley  Smith,  "  cause  and  effect 
react  upon  each  other  in  a  Vicious  Circle  and  the 
glaucoma  intensifies  itself."1 

In  the  healthy  eye  the  intra-ocular  fluid,  after 
being  secreted  by  the  capillaries  of  the  ciliary  pro- 
cesses, passes  into  the  posterior  and  then  through  the 
pupil  into  the  anterior  aqueous  chamber,  filters 
through  the  meshes  of  the  ligamentum  pectinatum 
and  spaces  of  Fontana,  and  escapes  into  the  canal 
of  Schlemm  and  thence  into  the  anterior  ciliary 
veins,  a  state  of  equilibrium  being  maintained  by  a 
self-regulating  mechanism. 

1  Internation.  Ophthalmologen  Congress,  Heidelberg,  1888, 
p.  243.  Cf.  also  Norris  and  Oliver,  System  of 
Diseases  of  the  Eye,  III.,  p.  648.  Pinto  describes 
no  less  than  five  processes  by  which  glaucoma  may 
perpetuate  itself.  Encyclopedic  Fran9aise  d'  Ophtal- 
mologie,  V.,  pp.  109,  113,  121,  124,  128, 


176 IDlctcmg  Circles  in  Disease 

In  glaucoma  this  equilibrium  is  disturbed,  with 
the  result  that  the  intra-ocular  pressure  rises.  The 
exact  mechanism,  however,  is  not  fully  understood, 
and  a  variety  of  theories  have  been  suggested. 

According  to  the  popular  retention  theory,  the 
root  of  the  iris,  is  under  certain  predisposing  con- 
ditions, approximated  to  the  root  of  the  cornea, 
diminishing  the  nitration  angle,  hindering  the  escape 
of  the  intra-ocular  fluid  and  raising  the  pressure  in 
the  whole  eye-ball.1  This  impedes  the  flow  of  blood 
through  the  choroidal  veins  and  adds  to  the  con- 
gestion of  the  ciliary  processes.  As  a  result  of  these 
factors  the  increased  quantity  of  intra-ocular  fluid 
pushes  forward  the  lens  and  iris,  further  blocking 
the  filtration  angle  and  checking  excretion.2 

Lawson  writes  : 

"  The  sudden  raising  of  the  intra-ocular  pressure 
increases  the  congestion,  to  be  followed  in  its  turn  by 
a  serous  exudation  from  the  venous  channels,  with 
a  consequent  further  increase  of  pressure  ;  and  thus  a 
Vicious  Circle  is  quickly  established,  with  symptoms 
of  ever-increasing  violence."3 

Kuschel  believes  that    other    factors    contribute 

to  the  progressive  increase  of  intra-ocular  pressure  : 

"  The   increased   pressure   in  the   vitreous  humour 

forces  the  coronary  division  of  the  hyaloid  membrane 

JThe  normal  intra-ocular  pressure  of  about   25   mm.   Hg 
may  in  glaucoma  rise  to  60  mm. 

2  It  is  well  to  remember  that  correlations  that  appear  to  us 

injurious  may  with  the  progress  of  knowledge  come 
to  bear  another  explanation.  Thus  in  1867  Wecker 
suggested  a  different  cause  of  glaucoma  :  "  The 
diminished  elasticity  of  the  sclerotic  plays  a  highly 
important  role.  It  establishes  a  Vicious  Circle  in 
respect  of  the  ciliary  nerves,  which  are  more  and 
more  compressed."  Maladies  des  Yeux,  I.,  p.  502. 

3  Diseases  and  Injuries  of  the  Eye,  p.  236.     Cf-  also  Hender- 

son, Glaucoma,  p,   I3r, 


anb  iB^lifcs  177 


(vorderer  Grenzschicht)  into  the  intervals  between 
the  ciliary  folds  (Ciliartaler)  and  thus  blocks  them.  As 
a  result  fluid  can  no  longer  escape  from  the  vitreous 
in  consequence  of  which  a  further  rise  in  pressure  takes 
place,  followed  by  a  further  blocking  of  the  inter-ciliary 
spaces.  The  Vicious  Circle  thus  established  leads  to 
an  enormous  increase  of  intra-vitreous  pressure  and 
to  a  complete  arrest  of  the  circulation  of  intra-ocular 
fluids." 

And  again  : 

"  The  increased  tension  in  the  vitreous  exerts  severe 
pressure  on  the  choroid  especially  on  its  anterior 
section  .  .  .  Hence  results  partial  or  complete  obstruc- 
tion to  the  venous  flow  through  the  ciliary  processes, 
whose  veins  open  into  the  anterior  venae  vorticosse. 
The  ciliary  processes  consequently  become  disturbed 
and  encroach  upon  or  even  entirely  obliterate  the 
inter-ciliary  spaces.  In  this  way  another  Vicious 
Circle  is  established  which  must  further  raise  the 
pressure  in  the  vitreous."  1 

According  to  Fischer  glaucoma  is  due  to  an  abnor- 
mal absorption  of  water  by  the  colloids  contained  in 
the  eye.  The  resulting  swelling  of  the  colloids  then 
compresses  the  blood-vessels  passing  into  or  out  of 
the  eye.  Hence  the  glaucoma  has  a  tendency  to 
self-  aggravation.2 

Even  so  simple  a  disorder  as  eye-strain  may  at 
times  suffice  to  start  the  morbid  sequence  of  events, 
at  any  rate  in  a  small  eye  that  is  so  to  speak  pre- 
disposed by  a  hypertrophied  ciliary  muscle. 

Clarke  thus  alludes  to  the  setiological  factors  : 

"  The  congestion  caused  by  the  eye-strain  leads  to 
hyper-secretion,  perhaps  to  a  mild  form  of  cyclitis  : 

1  Der  Intra-Okulare  Fliissigkeitsstrom  in  seinen  Beziehungen 

zum  biomechanischen  Aufbau  des  Auges  unter 
gesunden  Verhaltnissen,  beim  Glaukom  und  bei 
der  Kurzsichtigkeit,  pp.  120,  129. 

2  (Edema  and  Nephritis,  pp.  7,  61,  653-4. 


178          IDtcloug  Circles  in  Bisease 

obstruction  at  the  filtration  angle  takes  place,  tension 
goes  up  and  a  Vicious  Circle  is  established.  If  the 
eye-strain  is  removed  by  correcting  the  error  the  attack 
may  be  indefinitely  postponed."1 

In  the  later  stages  of  glaucoma  the  walls  of  the 
eye-ball  are  gradually  stretched  and  thinned,  some- 
times in  the  region  of  the  equator,  sometimes  in  the 
ciliary  zone.  These  processes  of  stretching  and 
thinning  aid  and  abet  each  other,  and  occasionally 
end  in  rupture  of  the  globe. 

Reciprocal  relations  also  complicate  secondary 
glaucoma,  as  for  example  where  staphyloma  results 
from  perforation  of  the  cornea  associated  with 
cicatrisation  of  the  prolapsed  iris.  There  is  then 
more  or  less  complete  obliteration  of  the  filtration 
angle,  followed  by  increased  tension  and  increased 
staphyloma. 

The  sequence  is  described  by  Kick  : 

"  Staphyloma  corneae  is  a  corneal  scar  which,  with 
the  adherent  iris,  bulges  outward.  .  .  .  The  adhesion 
of  the  iris  to  the  cicatrizing  cornea  produces  traction 
on  the  ciliary  body,  that  vascular  and  nervous  part  of 
the  inner  tunic  of  the  eye  by  which  the  aqueous  humour 
is  secreted.  Irritation  of  the  ciliary  body — so  it  is 
assumed — increases  secretion  ;  the  internal  pressure 
of  the  eye  is  thereby  raised.  This  heightened  tension 
pushes  the  scar  forward  with  greater  force  ;  the 
ciliary  body  is  thereby  still  more  dragged  upon,  with 
the  consequence  of  shutting  up  the  circulus  vitiosus"'2- 

Retinitis.  Various  affections  of  the  retina  are 
liable  to  be  complicated  by  harmful  circular  reactions. 
An  example  is  met  with  in  myopic  persons  with 
retinal  hyperaesthesia  and  muscae  volitantes. 

1  Clinical  /.,  XXXVI.,  p.  322. 

2  Diseases  of  the  Eye  and  Ophthalmoscopy,  p.  257. 


anb  i£\>e<*lib0  179 


L,andolt  writes  : 

"  The  myope  sees  these  phenomena  with  greater  ease, 
because  he  is  seldom  adapted  to  the  source  of  light. 
Moreover,  when  the  myopia  is  pernicious,  the  sensitive- 
ness of  the  retina  undergoes,  from  the  beginning,  a 
pathological  exaggeration.  Later  on,  to  these  almost 
physiological  corpuscles  are  added  others  which  are  due 
to  the  retinal  and  choroidal  exudation.  The  latter 
are  now  more  numerous,  larger  and  more  troublesome 
and  disquieting  to  the  patient.  He  ascribes  to  them 
all  kinds  of  shapes,  and  never  wearies  of  their  descrip- 
tion, which  he  willingly  accompanies  with  a  faithful 
sketch.  This  is  a  proof  of  the  torments  to  which  they 
subject  him  and  of  the  anxiety  with  which  he  observes 
them.  This  observation  itself  places  him  in  a  Vicious 
Circle  of  action  and  reaction,  for  the  more  he  pursues 
these  phantoms,  the  more  he  is  harassed  by  them, 
nothing  being  more  fatiguing  than  the  observation  of 
such  entoptic  phenomena.  Thus  it  is  that  they 
become  a  cause,  both  direct  and  indirect,  of  the  weaken- 
ing of  the  eyesight."  1 

Various  other  local  conditions  arouse  injurious 
auto-suggestions  in  neuropathic  individuals  and 
feed  the  neurosis.  Thus  a  trifling  hypersesthesia 
may  lead  to  the  adoption  of  injudicious  procedures, 
as  for  instance  when  recourse  is  had  to  tinted  lenses 
and  darkened  rooms,  which  only  serve  to  increase 
the  trouble.  Even  apart  from  hyperaesthesia  some 
persons  wear  tinted  glasses,  what  Bonders  terms 
"  conservative  spectacles,"  on  account  of  their 
agreeable  and  soothing  effect.  Such  glasses  with- 
draw the  healthy  stimulus  of  white  light,  intensify 
the  retinal  sensitiveness,  and  thus  create  a  perman- 
ent necessity  for  their  employment. 

A  more  serious  disorder  may  be  associated  with 
papilloedema.  The  primary  cause  is  usually  found 
in  an  increase  of  intra-cranial  pressure  due  to  hydro- 


1  Refraction  and  Accommodation  of  the  Eye,  p.  457. 


I&Q  IDtctoug  Circles  in  Disease 

cephalus  or  a  new  growth,  which  forces  the  subar- 
achnoid  fluid  into  the  sheaths  of  the  optic  nerve. 
Hence  result  engorgement  of  the  central  vein  of  the 
retina,  oedema  of  the  optic  nerve,  and  swelling  of 
the  papilla.  The  nerve  becomes  incarcerated  at 
the  point  where  it  fits  tightly  in  the  foramen  sclerse, 
and  causes  strangulation  of  the  papilla  and  further 
engorgement  in  the  vein.  The  oedema  provokes 
strangulation  and  the  strangulation  oedema. 

Dacryo- Cystitis.  An  injurious  reciprocation  may 
occur  in  cases  of  dacryo-cystitis  owing  to  stricture 
of  the  lachrymal  duct.  The  trouble  begins  with 
congestion  of  the  lachrymal  sac,  causing  some 
obstruction  of  the  duct,  which  in  turn  is  followed  by 
excessive  flow,  stagnation  and  decomposition  of  the 
secretions.  The  consequent  irritation  produces  fur- 
ther narrowing,  often  ending  in  complete  obstruction. 

Evans  writes  : 

"  The  irritation  of  the  sac  and  conjunctiva  sets  up 
an  excessive  reflex  secretion  of  tears,  and  thus  is 
established  a  Vicious  Circle  which  perpetuates  the 
inflammation  and  distension  of  the  sac."  1 

As  a  further  result  of  the  constant  distention 
of  the  lachrymal  sac  by  the  fluid,  the  walls  gradually 
lose  their  elasticity  so  that  the  tears  no  longer  pass 
into  the  nose,  even  when  the  duct  again  becomes 
patent.  The  sac  tends  to  grow  steadily  larger  until 
a  conspicuous  fluctuating  mucocele  is  produced. 

II.     THE   EYE-IylDS 

The  eye-lids  have  already  been  alluded  to  more 
than  once  as  associated  with  diseases  of  the  eyes. 
Some  additional  illustrations  of  circular  reactions 
may  be  given  under  a  special  heading. 

1  British  Med.  J.,  1907,  I.,  p.  420. 


anb  E^libs  181 


Ectropion.  Kctropion  is  a  common  self-per- 
petuating disorder  which  both  results  from,  and 
provokes,  epiphora  ;  any  attack  of  persistent  epi- 
phora that  produces  a  macerated  and  contracted 
state  of  the  skin  of  the  lower  lid  may  start  the  process 
(platC  IX.  c).  The  contraction  of  the  skin  draws 
down  the  margin  of  the  lid  and  leads  to  eversion  of 
the  punctum,  this  being  followed  by  increased 
epiphora. 

Panas  writes  : 

"  The  skin,  incessantly  irritated  by  the  tears  flowing 

over  it,  contracts  more  and  more,  thus  establishing  a 

Vicious  Circle  which  ends  in  ectropion."  l 

An  example  of  these  correlations  is  met  with  in 

elderly  persons  in  whom,  owing  to  diminished  elasticity 

of  the  skin,  the  lower  lid  is  apt  to  drop  away  from  the 

eye-ball,  leaving  the  conjunctiva  exposed.     In  course 

of  time  the  conjunctiva  undergoes  hypertrophy  and 

the  increased  weight  leads  to  further  displacement. 

The  resulting  epiphora  is  apt  to  provoke  an  ecze- 

matous  condition  of  the  lower  lid  (tinea  or  ophthal- 

mia tarsi),  and  thus  further  aggravates  the  displace- 

ment. 

Fuchs  writes  : 

"  As  a  consequence  of  the  wetting  with  the  tears, 
the  skin  of  the  lower  lid  is  attacked  with  eczema  or 
becomes  rigid  and  contracted,  so  that  the  free  edge  of 
the  lid  is  no  longer  in  perfect  apposition  with  the 
eye-ball.  As  a  result  of  this  the  punctum  lacrimale 
no  longer  dips  into  the  lacus  lacrimalis,  so  that  the 
transportation  of  the  tears  into  the  lachrymal  ,  sac  is 
impeded,  the  epiphora  increased,  and  thus  again  a 
still  further  injurious  reaction  upon  the  character  of 
the  skin  is  produced.  In  this  way  there  is  formed  a 
Vicious  Circle  which  leads  to  a  constantly  increasing 
depression  of  the  lower  lid  (ectropion)."2 

Maladies  des  Yeux,  II.,  p.  333. 

2  Text-Book  of   Ophthalmology,   p.    148.     Cf.    also    Berry, 
Diseases  of  the  Eye,  p.  58. 


182          IDtctoug  Circles  in 


In  order  to  mop  up  his  tears  the  sufferer  usually 

wipes  from  above  downwards  and  so  increases  the 

malposition  ;   a  better  plan  is  to  wipe  the  face  from 

below  upwards  so  as  to  press  the  lid  back  into  place. 

Clarke  writes  : 

"  The  causes  of  this  eversion,  which  displaces  the 
punctum,  are  many.  Among  the  most  common  are 
chronic  inflammation  of  the  lid  and  conjunctiva, 
granular  lids  and  blepharitis.  The  lid  becomes  thick- 
ened, the  punctum  is  drawn  away  from  the  eye,  epiphora 
results  ;  this  causes  irritation  of  the  skin,  which  leads 
to  contraction,  causing  more  eversion,  and  in  a  very 
short  time,  through  the  Vicious  Circle  of  events,  a  well- 
marked  ectropion  exists."1 

Bishop  Harman  also  writes  : 

"  There  is  set  up  a  Vicious  Circle.  The  blepharitis 
predisposes  on  even  slight  provocation  to  conjunc- 
tivitis and  eczema  of  the  skin,  and  these  in  turn  exagger- 
ate the  blepharitis  ;  ultimately  both  cilia  and  Meibonian 
glands  may  be  destroyed."2 

Prolonged  epiphora  may  in  itself  lead  to  blephar- 
itis since  cicatricial  tissue  resulting  from  the  blephar- 
itis causes  the  conjunctiva  to  be  drawn  forwards  over 
the  lid,  thus  thickening  its  edge  and  preventing  its 
close  application  to  the  eye-bail.  As  a  result  tears 
now  run  down  over  the  lid  and  intensify  the  blephar- 
itis. Tears  in  fact  do  no  little  damage  to  the  eye. 

Another  form  of  ectropion  sometimes  occurs  in 
connection  with  chemosis  of  the  eye-lids,  when  the 
bulging  conjunctiva  stretches  the  ciliary  portion  of 
the  orbicularis,  the  contraction  of  which  causes 
eversion  of  the  lid.  The  everted  lid  and  contracting 
orbicularis  then  act  like  a  ligature  and  aggravate  the 
chemosis  by  strangulating  the  conjunctival  veins. 

1  Clinical  /.,  XVI.,  p.  67.     Cf.  also  Roemer,  Text-Book  of 

Ophthalmology,  p.  298. 
2L.c.,  XXVIII.,  p.  361. 


anfc  £^e^Ub9  183 


A  similar  form  of  spastic  ectropion  not  infrequently 
follows  an  attempt  to  open  the  palpebral  fissure  in  a 
child    with    swollen    lids    and    blepharospasm. 
Weeks  writes  : 

"  Examples  of  this  form  of  ectropion  are  observed  in 
infants  with  ophthalmia  neonatorum.  In  attempts  to 
treat  the  conjunctiva  slight  traction  is  made  on  the 
skin  of  the  lids.  The  infant  cries,  blepharospasm 
is  induced,  and  the  lids,  both  upper  and  lower,  become 
everted.  With  increase  of  spasm,  venous  congestion 
becomes  marked,  and  the  ectropion  may  be  perpetuated. 
Ectropion  formed  in  this  way  is  complete."  l 

Entropion.  Hntropion  is  frequently  caused  by 
incurvation  of  the  lid  margins  through  spasmodic 
contraction  of  the  ciliary  fibres  of  the  orbicularis, 
and  then  perpetuates  itself  through  the  associated 
trichiasis  (JMatC  IX.  d).  The  condition  is  often 
seen  under  circumstances  of  relaxation  and  oedema 
of  the  skin  and  loss  of  subcutaneous  fat  ;  thus  it 
occurs  after  cataract  extraction  in  old  people. 

Terson  writes  : 

"  When  once  the  displacement  of  the  lid  has  occurred 
a  Vicious  Circle  is  established,  for  the  subcutaneous 
oedema  is  increased  by  the  irritation  of  the  trichiasis 
and  can  only  be  arrested  when  the  eye-lid  has  been 
replaced  by  traction."2 

Cicatricial  entropion  may  be  associated  with  con- 
traction of  the  conjunctiva  and  cartilage  ;  the 
commissure  is  frequently  narrowed,  producing  what 
is  known  as  blepharophimosis  and  further  increasing 
the  tendency  to  inversion.  Muscular  spasm  and 
trichiasis  frequently  act  as  aggravating  factors. 

In  other  cases  of  entropion  with  blepharospasm 
a  superficial  ulceration  is  caused  by  the  folding 
of  the  skin  at  the  outer  canthus  and  by  the 

1  Treatise  on  Diseases  of  the  Eye,  p.  189. 

2  Encyclopedic  Francaise  d'  Ophtalmologie,  V.,  p.  505. 


184 IDidous  Circles  in  Disease 

conjunctival  discharges.  This  ulceration  by  reflex 
irritation  increases  the  spasm  and  acts  as  an  impor- 
tant factor  in  maintaining  the  irritation  of  the  eye. 

III.     ERRORS    OF    REFRACTION 

Every  error  of  refraction  may  at  times  be  com- 
plicated by  self -perpetuating  factors.  Many  of  these 
are  associated  with  asthenopia. 

Myopia.  There  has  been  much  discussion  as  to 
the  aetiology  of  myopia.  There  is  general  agree- 
ment that  the  disorder  is  acquired  through  elongation 
of  the  eye-ball,  but  doubt  exists  as  to  the  cause  of 
this  elongation  ((Mate  IX.  e). 

The  older  view  attributed  the  elongation  to  pres- 
sure on  the  eye  associated  with  convergence,  the 
injury  being  most  easily  produced  in  children  whose 
ocular  tissues  had  not  reached  their  full  power  of 
resistance.  The  greater  the  pressure  the  more  the  eye- 
ball tended  to  yield  ;  the  more  the  eye-ball  yielded 
the  greater  the  convergence  required  for  clear  vision. 

This  view  was  held  by  L,andort  who  writes  : 

"  The  influence  of  near  work  may  manifest  itself  in 
different  ways.  It  will  be  noticed  even  that  the  three 
principal  modes  of  production  of  myopia  that  we  have 
mentioned  are  so  intimately  related  to  each  other 
that  one  of  them  necessarily  suggests  the  others. 
Exaggeration  of  convergence  leads  to  that  of  accommo- 
dation. The  latter  of  itself  alone,  and  also  by  the 
excessive  nearness  of  the  object  which  it  necessitates, 
and  the  position  which  gives  rise  to  cephalic  hvperrcmia, 
favours  the  production  of  choroiditis.  The  affection 
of  the  membranes  of  the  fundus  oculi  entails  a  diminu- 
tion of  the  acuteness  of  vision,  which,  in  its  turn,  makes 
the  gradual  approach  of  the  object  and  exaggeration  of 
convergence  obligatory. 

.Sometimes  this  Vicious  Circle  will  be  opened,  on 
the  contrary,  by  diminution  of  the  acuteness  of  vision, 
and,  at  other  times,  by  a  spasm  of  accommodation. 
But  at  whatever  point  this  wheel  of  misfortune 


anb  iB^c^libe  185 


takes  up  the  victim,  he  must  go  round  with  it,  and 
will  have  to  inexorably  pass  through  the  series  of 
injurious  influences,  which  reinforce  each  other  to 
aggravate  the  evil.  When  we  take  into  consideration 
this  linking  together  of  harmful  causes,  we  are  no 
longer  surprised  at  the  rapid  and  constant  progress 
made  by  myopia  in  an  eye  which  it  has  once  attacked, 
especially  when  the  latter  has  been,  from  birth,  disposed 
to  it,  or  is  deprived  of  the  ability  to  resist  it."  l 

There  are,  however,  various  objections  to  this 
explanation  which  has  been  to  a  large  extent 
abandoned. 

According  to  Eldridge  Green  myopia  is  probably 
due  to  some  obstruction  to  the  outflow  of  lymph 
into  the  lymph  spaces  of  the  optic  nerve.2  Such 
obstruction  increases  the  intra-ocular  tension,  dis- 
tends the  sclerotic  posteriorly  where  it  is  weakest 
and  causes  myopia  by  elongation  of  the  eye-ball. 
Any  great  physical  exertion  or  even  violent  coughing 
may  cause  such  obstruction,  and  when  once  the 
sclerotic  has  given  way,  its  resulting  weakness  will 
predispose  to  further  yielding.  The  progressive 
nature  of  the  disease  is  thus  readily  explained. 

Myopia,  when    once    established,  often   produces 
much   local   discomfort   which   affects   the   general 
health  and  lowers  vitality,  especially  in  the  case  of 
children  and  neuropathic  individuals. 
Lawson  writes  : 

"  The  general  health  in  young  children  often  suffers 
greatly  from  the  aching  and  general  discomfort  they 
experience,  and  in  this  way  a  Vicious  Circle  may  be 
established  which  favours  the  rapid  advance  of  the 
disease."8 

1  Refraction  and  Accommodation  of  the  Eye,  p.  454.  Cf. 
also  Noyes,  Diseases  of  the  Eye,  p.  64  ;  Trans,  of 
the  Ophthalmological  Society  of  the  U.K.  (1907), 
XXVII.,  p.  12. 

"-Lancet,  1918,  1.,  p.  137. 

3  Diseases  and  Injuries  of  the  Eye,  p.  67. 


186  IDicioue  Circles  in 


Myopia  and  spinal  curvature  also  stand  in  re- 
ciprocal relation,  if  Liebreich's  views  may  be 
accepted  : 

"  Spinal  curvature  and  short-sightedness  seem  to 
form  a  circulus  vitiosus,  in  so  far  as  short-sightedness 
produces  curvature,  and  curvature  favours  short-sight- 
edness ;  while  evidently  the  same  bad  arrangements 
are  at  the  foundation  of  both  these  anomalies."1 

Hypermetropia.  Hypermetropic  asthenopia  is 
frequently  a  self-  aggravating  disorder.  The  over- 
strained accommodation  causes  the  removal  of  any 
small  object  looked  at  to  a  greater  distance  and  thus 
leads  to  diminished  acuity  of  vision.  This  latter 
compels  the  sufferer  to  attempt  closer  work,  involving 
increased  effort  of  accommodation.  Thus  the  two 
factors  of  over-strained  accommodation  and  indis- 
tinct vision  react  on  each  other. 

Presbyopia.  A  similar  complication  comes  into 
operation  with  the  advent  of  presbyopia  as  a  result 
of  the  effort  to  obtain  distinct  vision  by  accommoda- 
tion. Owing  to  the  great  distance  at  which  the 
presbyope  reads,  the  retinal  image  is  small  and  indis- 
tinct, and  this  tempts  him  to  bring  his  work  closer 
to  his  eyes.  At  the  nearer  distance,  however,  he 
overtaxes  his  accommodation,  and  this  in  return 
renders  his  work  indistinct  and  again  compels  its 
removal. 

Anisometropia.  Another  self-intensifying  dis- 
order is  anisometropia  caused  by  exhaustion  of  the 
fusion  centre  and  of  the  muscles  of  accommodation. 
Bach  of  these  factors  reacts  injuriously  on  the  other. 

Doyne  writes  : 

"  The  trouble  arises  from  a  Vicious  Circle.  The 
fusion  centre  demands  clear  images  and  makes  demands 
on  the  lower  centres  which  control  the  muscles  of  the 

1  School  Life  in  its  Influence  on  Sight  and  Figure,  p.  16. 


anb  iS^e^Itbg  187 


eyes  ;  the  muscles  become  exhausted,  the  images 
become  indistinct  and  the  fusion  centre  becomes  more 
imperious,  as  its  task  becomes  more  difficult.  Moreover, 
all  these  details  are  mainly  subconscious  and  inde- 
pendent of  the  will."1 

Much  the  same  correlations  may  complicate 
astigmatism.  The  associated  eye-strain  involves  a 
serious  drain  on  the  vital  forces  and  their  diminution 
involves  further  eye-strain. 

IV.     NEUROSES 

Various  ocular  neuroses  have  been  already  referred 
to  in  connection  with  special  disorders.  Such  for 
example  are  the  auto-suggestions  connected  with 
muscse  volitantes  in  the  myope  and  the  asthenopia 
which  complicates  so  may  errors  of  refraction.  The 
latter  neurosis  is  so  important  as  to  demand  a 
further  reference. 

Asthenopia.  Asthenopia  is  a  wide-spread  dis- 
order, especially  in  young  persons  whose  ocular 
tissues  possess  little  power  of  resistance,  or  in  neuro- 
paths whose  nervous  capital  is  limited  and  readily 
used  up.  The  weakened  tissues  of  children  are  mainly 
concerned  in  progressive  myopia,  while  neuropaths 
suffer  most  from  astigmatism  or  anisometropia. 

Asthenopia  may  show  itself  in  various  ways.  At 
times  there  is  a  continual  sense  of  fatigue,  headache 
or  photophobia,  caused  by  the  abnormal  and  some- 
times unsymmetrical  effort  of  the  ciliary  and  other 
ocular  muscles  to  secure  accommodation  and  bino- 
cular vision.  The  necessary  effort  consumes  much 
energy  and  soon  brings  on  exhaustion  (JMfltC  IX,  f). 
There  is  what  Goodhart  calls  a  want  of  "  watts, 
amperes  and  volts  of  nervous  energy."2 

In  such  a  state  of  exhaustion  increased  effort  is 
required  both  in  order  to  correct  refraction  and  to 
secure  clear  images,  and  still  greater  and  wasteful 

1  British  Med.  /.,  1910,  II.,  p.  363. 
z  Lancet,  1916,  I.    1122. 


i88  IDidous  Circles  in  Disease 

expenditure  results  ;  nervous  bankruptcy  may  super- 
vene. Insomnia  occasionally  constitutes  an  aggrava- 
ting factor  ;  the  restorative  influence  of  sleep  is 
then  lost  and  the  pernicious  process  is  accelerated. 
Clarke  writes  : 

"  Insomnia  is  a  very  prominent  symptom  of  eye- 
strain  and  so  a  Vicious  Circle  is  started.     Eye-strain 
produces  among  other  troubles  insomnia,  and  insomnia 
in  its  turn  aggravates  the  patient's  condition,  because 
the  all-important  restorative  is  wanting."  1 
In  yet  another  group  of  cases  asthenopia  impairs 
the  processes  of  digestion  and  assimilation.     Vitality 
is    depressed    and   this    renders   the    nervous    and 
muscular  tissues  still  more  vulnerable  to  the  abnor- 
mal strain  thrown  upon  them. 

"  There  is  a  Vicious  Circle  of  cause  and  effect. 
Eye-strain  with  its  pain  and  nervous  disturbances, 
produces  interference  with  assimilation  and  nutrition, 
which  in  its  turn  so  reduces  the  general  physical  con- 
dition as  to  induce  an  increase  in  the  asthenopia."2 

Shell  Shock.  The  wide-spread  use  of  high  explo- 
sives in  the  recent  war  has  supplied  numerous 
examples  of  neuroses  in  soldiers  suffering  from  shell 
shock.  Such  soldiers  may  complain  of  blindness 
although  no  injury  can  be  discovered  which  would 
account  for  the  loss  of  sight.  By  a  process  of  sugges- 
tion the  visual  perception  structures  in  the  brain  may 
have  been  dissociated  from  the  nervous  tracts  con- 
veying the  light  stimuli  from  the  eyes.  The  man 
is  blind  because  he  believes  he  is  blind  and  makes  no 
attempt  to  use  his  eyes.  Such  auto-suggestions  are 
of  course  commonest  in  individuals  with  neuropathic 
introspective  proclivities.  Similar  dissociation  pro- 
cesses may  cause  sufferers  from  severe  shock  to 
become  deaf  or  mute. 

1  Practitioner,  1911,  I.,  p.  26. 

2Norris  and  Oliver,  System  of  Diseases  of  the  Eye,  IV., 

p.   405.      Cf.   also   Gould,    British   Med.   /.,    1903, 

II.,  p.  663. 


Chapter  Eleven 


THE   NOSE 

HE  rebellious  character  of  many  diseases  of 
the  nose  is  due  to  the  presence  of  self- 
perpetuating  conditions.  Amongst  them 
are  variations  in  the  calibre  of  the 
nasal  passages,  both  in  the  direction  of 
excess  and  deficiency.  These  will  be  dealt  with  first. 

Stenosis.  The  nasal  cavities  form  a  rigid  box 
with  highly  vascular  walls  through  which  flows  a 
tidal  current  of  air.  If  as  a  result  of  obstruction  to 
this  current  the  air  tension  is  diminished  the  vas- 
cular walls  become  distended  with  blood  and  lymph, 
and  so  to  speak  a  dry  cupping  process  is  initiated. 
If  this  process  is  long  continued  a  chronic  condition 
of  congestion  and  catarrh  will  result,  ending  in  a 
permanent  vaso-motor  paresis  and  hyperplasia. 

Such  primary  obstruction  may  be  due  to  a  variety 
of  causes  including  injury,  neglected  or  recurrent 
colds  and  so  forth.  The  mucosa  is  maintained  in  a 
state  of  congestion,  loses  its  contractility  and  gradu- 
ally undergoes  hypertrophy.  These  conditions  then 
aggravate  the  obstruction  to  which  they  were  due. 

Scanes  Spicer  writes  : 

"  Causative  stenosis  is  followed  by  hypertrophic 
catarrh.  Hypertrophic  catarrh  causes  increased  obstruc- 
tion, and  so  a  Vicious  Circle  is  created,  the  circumfer- 
ence of  which  is  far-reaching  and  ever-widening."1 

1  British  Med.  /.,  1900,  II.,  p.  346.     Cf.  also  Gradle,  Diseases 

of  the  Nose,  Pharynx  and  Ear,  p.  46. 
189 


Dicious  Cirdes  in  ^Disease 


Stenosis  may  also  call  forth  other  conditions 
which  maintain  the  stenosis.  Thus  behind  the 
point  of  obstruction  the  inspiratory  pressure  will  be 
less  than  in  a  patent  nostril  and  this  diminished 
pressure  perpetuates  the  turgescence  and  promotes 
further  hypertrophy.  Again  when  once  establish- 
ed the  stenosis  interferes  with  the  expulsion  of 
secretions  and  favours  an  accumulation  which 
increases  the  obstruction.  L,ike  all  cavities  lined 
with  mucous  membrane  the  nostrils  tend  to  become 
narrowed  when  their  drainage  and  ventilation  are 
interfered  with. 

Yearsley  writes  : 

"  Defective  drainage  of  the  nasal  cavities  predisposes 
to  microbic  infections  and  their  resulting  inflammations. 
Bacteria  find  a  suitable  nidus  behind  a  septal  deflection, 
and  the  result  is  that  recurrent  attacks  of  rhinitis  occur, 
each  attack  leaving  the  patient  with  increased  obstruc- 
tion and  greater  tendency  to  fresh  infection  ;  conse- 
quently a  Vicious  Circle  is  established  of  obstruction, 
defective  drainage,  rhinitis,  increased  obstruction. 
This  is  the  mechanism  by  which  patients  with  nasal 
obstruction  are  so  frequently  the  victims  of  the  common 
cold.  But  the  results  of  the  Vicious  Circle  are  more 
far-reaching  than  may  appear  on  the  surface."1 

Deflection  of  the  septum  is  another  cause  of 
stenosis  on  the  convex  side,  since  such  deflection 
leads  to  diminished  tension  behind  the  obstruction 
and  such  diminution  tends  to  increase  the  deflection. 

Watson-  Williams  writes  : 

"  As  a  consequence  of  the  partial  nasal  obstruction 
from  deflected  septum,  inspiration  causes  a  rarefaction 
of  the  air  behind  the  obstruction  ;  as  a  consequence 
over-filling  of  the  vessels  and  constant  hypersemia 
with  chronic  rhinitis  and  further  increase  of  the  nasal 
stenosis  may  result."2 

1  Practitioner  ,  1914,  II.,  p.  503. 

2  Diseases  of  the  Upper  Respiratory  Tract,  p.  337. 


tlbc  IRose 


191 


(a)  NASAL  STENOSIS 


(b)  NASAL  DILATATION 


(c)  ULCER  OF  SEPTUM 


""% 


(d)  SINUSITIS 


(e)  POLYPUS 


(f)  RHINOLITH 


IPlatc  X.— Circles  aseociateb  witb 
the  lRo0e. 


192  Dicioue  Circles  in  Disease 

Riseley  draws  attention  to  the  "  Vicious  Circle 
of  events  "  which  occurs  when,  owing  to  deformities 
of  the  scroll  bones  of  the  nostrils  and  to  deviations 
of  the  septum  or  vomer,  the  nasal  chamber  is  so 
narrowed  that  the  opposing  sides  come  into  contact, 
or  approach  so  nearly  that  any  congestion  of  the  lining 
mucosa  brings  them  together.  Here,  too,  a  self -ag- 
gravating factor  comes  into  play,  since  the  oppos- 
ing pressures  perpetuate  the  congestion.  Congestion 
breeds  congestion.  The  nose  is  choked  by  the 
turgid  soft  tissues  and  drainage  is  checked.1 

Obstruction  is  frequently  caused  by  adenoids, 
which  tend  to  enlarge  as  the  result  of  the  asso- 
ciated catarrh  and  infection. 

Fraser  writes  : 

"  In  case  of  adenoids  a  Vicious  Circle  is  set  up.  The 
child  suffers  from  attacks  of  coryza  which  cause 
enlargement  of  the  naso-pharyngeal  tonsil.  This  again 
gives  rise  to  nasal  obstruction  and  tends  to  keep  up 
the  catarrhal  condition  of  the  nose  and  naso-pharynx, 
and  predisposes  the  child  to  fresh  attacks  of  cold  in 
the  head."2 

Adenoid  growth  is  also  favoured  by  the  factor 
already  alluded  to,  viz.  the  diminished  barometric 
pressure  accompanying  the  act  of  inspiration  in 
cases  of  nasal  obstruction.  Every  such  act  di- 
minishes the  pressure  behind  the  obstruction,  leads 
to  hypersemia  and  hyperplasia  and  so  tends  to  further 
adenoid  growth.  Many  children  rind  it  difficult  to 
clear  their  naso-pharynx  from  the  secretions  produced 
by  adenoids.  These  secretions  then  increase  the 
irritation  and  further  obstruct  the  naso-pharynx. 
Eventually  the  child  is  forced  to  breathe  through 

1  British  Med.  J.,   1906,  II.,  p.    1869.  Cf.   also    Ballenger, 

Diseases  of  the  Nose,  Throat  and  Ear,  p.  142. 

2  Encyclopaedia  Medica,  L,  p.  169.     Cf.  also  Crowley,  The 

Hygiene  of  School  Ivife,  p.  38, 


She  Itiose  193 


the  mouth  and  this  introduces  a  fresh  factor  which 
further  intensifies  the  stenosis.  In  the  absence  of 
the  normal  currents  of  air  through  the  nose  secretions 
tend  to  accumulate  and  undergo  decomposition, 
with  the  result  that  the  mucous  imembrane  is 
maintained  in  a  state  of  chronic  hypersemia  (JMatC 
X.  a). 

As  Mayo  Collier  says  : 

"  Mouth-breathing  introduces  a  further  aggravating 
factor.  A  Vicious  Circle  is  set  up  ;  mouth-breathing 
tends  to  obstruct  the  nose,  and  this  very  obstruction 
maintains  and  continues  the  mouth-breathing."1 

Another  sequence  of  reciprocal  events  may  be 
observed  in  cases  of  enlarged  tonsils,  when  these 
interfere  with  nasal,  and  thus  conduce  to  oral, 
respiration.  In  mouth-breathers  the  hypertrophied 
tonsils  are  readily  inoculated  by  any  air-borne 
contagion,  and  then  undergo  further  enlargement. 
Doubtless  the  enlargement  is  primarily  a  response 
to  a  demand  for  a  greater  leucocytic  activity  in 
order  to  get  rid  of  microbial  irritation  and  to  that 
extent  is  a  beneficent  reaction.  If,  however,  the 
enlargement  is  followed  by  mouth-breathing  more 
harm  is  done  than  good,  and  the  evil  is  aggravated. 

Bloch  writes  : 

"  Enlarged  tonsils  frequently  interfere  with  nasal 
respiration,  and  thus  cause  mouth-breathing,  which 
in  its  turn  acts  injuriously  on  the  tonsils  that  lie  directly 
in  the  air-current.  In  fact  these  organs  form  the  first 
important  obstruction  to  the  otherwise  almost  unim- 
peded current  of  air.  They  thus  serve  as  the  most 
convenient  site  for  the  deposition  of  the  grosser  impur- 
ities in  the  inspired  air,  and  give  rise  to  a  true  circulus 
vitiosus."* 

1  Mouth-breathing,    p.    12.    Cf.  also    Hogarth,    Medical  In- 

spection of  Schools,  p.  285. 

2  Die  Pathologic  und  Therapie  der  Mundatmung,  p.  73. 


i94          IDicious  Circles  in  Disease 

According  to  some  writers  adenoid  vegetations 
through  increased  activity  of  the  pharyngeal,  mylo- 
hyoid  and  other  muscles  lead  to  contraction  of  the 
mandible  and  maxilla,  and  vice  versa. 

Pickerill  writes  : 

"  A  Vicious  Circle  originates  in  the  following  way  : 

1.  A    common    cold    causes    blocking    of    the    nasal 
cavities,    swallowing    efforts    and    contraction    of    the 
mandible. 

2.  The   contracted    mandible   causes    contraction    of 
the  maxilla. 

3.  The  contracted  maxilla  causes  contraction  of  the 
nasal  cavities,  and  their  further  blocking  by  vegetation, 
and  this  leads  to  further  strained  deglutition."1 

Stenosis  is  liable  to  cause  collapse  of  the  alse  nasi. 
The  sides  of  the  nostrils  then  fall  inwards  on  inspira- 
tion instead  of  expanding,  and  may  convert  the 
anterior  nares  into  mere  slits.  In  severe  cases  the 
alse  may  actually  fall  against  the  septum. 
Gradle  writes  : 

"  Although  itself  the  consequence  of  some  intranasal 
anomaly  causing  stenosis,  it  (i.e.  the  collapse  of  the 
sides  of  the  nose)  intensifies  the  latter.  With  every 
inspiration  the  sides  of  the  external  nose  sink  in,  thereby 
slightly  narrowing  the  vestibule."2 

Dilatation.  It  is  interesting  to  observe  that 
abnormal  nasal  patency  may  also  be  a  self-perpetu- 
ating condition  (JMatC  X.  b).  This  may  be  illustrated 
by  the  course  of  events  in  a  case  of  atrophic  rhinitis, 
a  disorder  which  at  any  rate  in  its  later  stages  is 
closely  associated  with  undue  patency  of  the  nasal 
fossae  both  as  cause  and  effect.  So  wide  is  the 
nasal  cavity  as  frequently  to  allow  a  clear  view  of 
the  posterior  wall  of  the  pharynx. 

1  Dental  Caries  and  Oral  Sepsis,  pp.  60,  64.     Cf .  also  Stoma- 

tology, p.  28  ;    British  Med.  /.,  1914,  II.,  p.  1026. 

2  Diseases  of  the  Nose,  Pharynx  and  Ear,  p.  196. 


Iftose  195 


There  is  considerable  difference  of  opinion  as  to 
the  setiological  factors.  In  some  cases  atrophic 
rhinitis  results  from  a  diseased  state  of  the  nasal 
mucosa  associated  with  deficient  secretion  and 
the  formation  of  crusts.  In  other  cases  there  has 
been  deep  ulceration  or  necrosis  of  bone  or  cartilage. 
But  whatever  may  have  been  the  primary  cause 
atrophic  rhinitis  is  characterised  by  wasting  of  the 
soft  tissues  lining  the  nasal  fossae  as  well  as  of  the 
turbinated  bones,  combined  with  shrinking  of  the 
glands,  fatty  degeneration  of  their  epithelium  and 
diminution  of  the  secretion.  These  conditions  result 
in  an  abnormal  width  of  the  nasal  passages  from 
which  in  chronic  cases  the  turbinates  have  almost 
vanished,  leaving  a  dry,  pale  surface  with  adherent 
crusts. 

As  the  velocity  and  force  of  a  stream  grow  less 
with  a  wider  channel  so  does  the  air  passing  through 
such  dilated  nasal  passages  lose  the  velocity  and 
force  required  for  the  expulsion  of  tenacious  nasal 
secretions.  Hence  the  nasal  fossae  are  no  longer 
swept  clean  by  the  usual  tidal  air  currents  and 
the  secretions  become  inspissated  and  dry.  The 
adhesiveness  of  the  secretions  is  partly  due  to  the 
ciliated  epithelium  having  been  replaced  by  squam- 
ous  cells  owing  to  the  earlier  rhinitis,  partly  also  to 
the  secretions  contracting  like  a  film  of  collodium, 
causing  still  further  atrophy  of  the  soft  and  bony 
tissues  and  still  greater  nasal  patency.  Thus  the 
morbid  process  is  perpetuated,  and  we  have  the 
paradoxical  condition  of  dilatation  preventing  the 
removal  of  obstruction. 

In  many  cases  atrophic  rhinitis  is  complicated  by 
sinusitis,  the  two  disorders  favouring  each  other. 
Adam  writes  : 

"  In  most  cases  atrophic  rhinitis  is  the  end  stage 
of  a  chronic  hyperplastic  purulent  rhinitis,  involving 
first  the  membrane,  then  in  more  than  half  the  cases 
the  sinuses.  This  sinusitis,  by  a  Vicious  Circle,  reacts 


196          IDidous  <tirde0  in  2)isea0e 

on  the  membrane  and  perpetuates  the  inflammatory 
process  there."1 

In  other  cases  the  removal  of  a  polypus  seems 
to  supply  the  primary  stimulus  to  the  degenerative 
changes. 

MacDonald  writes  : 

"  After  the  removal  of  nasal  polypi  in  cases  where 
the  inferior  turbinals  had  previously  presented  a  normal 
appearance,  there  is  sometimes  induced  a  muco- 
pumlent  discharge,  which,  partly  from  its  tenacity,  and 
partly  on  account  of  the  unnaturally  widened  fossae,  the 
patient  is  unable  to  extrude.  It  putrefies  and  produces 
an  ozaenic  smell ;  it  dries  and  contracts  the  venous 
sinuses  of  the  erectile  tissue.  A  Vicious  Circle  is 
instituted,  which,  if  neglected,  might  presumably 
result  in  true  atrophy."2 

Rhinitis  sicca  is  almost  invariably  complicated 
by  the  presence  of  crusts,  associated  with  infective 
processes  which  lead  to  the  destruction  of  the  mucous 
membrane  and  cause  much  itching.  This  gives  rise 
to  nose-picking  with  further  injury  to  the  mucosa 
and  the  development  of  fresh  crusts  (platC  X.  c). 
Ribary  writes  : 

"  The  erosions  which  are  associated  with  anterior 
rhinitis  sicca  and  which  frequently  provoke  epistaxis, 
may  either  heal  or  give  rise  to  polypoid  excrescences 
(bleeding  polypus  of  the  septum),  or  they  may  extend 
to  the.  deeper  parts  and  lead  to  ulceration  by  means 
of  infective  processes.  Where  healing  has  taken  place, 
white,  tendon-like,  glistening,  tongue-shaped  processes 
of  epidermis  may  be  observed  to  extend  from  the  edge 
of  the  skin  on  the  septum  into  the  normal  mucosa. 
In  fact  as  a  result  of  the  morbid  process  the  mucous 
epithelium  has  perished,  and  been  replaced  by  epider- 
mis. The  new  epidermis  however  appears  to  have  less 
resisting  power  than  has  normal  cutis,  since  a  sense  of 

1  British  Med.  /.,  1908,  II.,  p.  1271. 

2Allbutt   and   Rolleston,   System   of    Medicine,    IV.     (ii.), 
p.  21  ;  Diseases  of  the  Nose,  p.  152. 


Cbe  Iftose  197 


tension  persists  and  results  in  renewed  nose-picking 
and  in  further  injury  to  the  mucosa  with  its  sequelae. 
In  this  way  a  circulus  vitiosus  forms  which  perpetuates 
the  disorder  and  generally  lasts  for  the  remainder  of 
life."1 

The  same  process  often  leads  to  a  perforating 
ulcer,  as  Griinwald  points  out  : 

"  I  have  observed  several  cases  of  this  kind  of  per- 
foration, and  the  Vicious  Circle  was  always  the  same  : 
crust  formation  on  the  septum  ;  picking  off  the  crust 
and  so  causing  bleeding,  which  led  to  the  formation  of 
a  larger  and  more  firmly  adherent  crust ;  and  so  on, 
the  whole  process  being  started  by  some  inflammatory 
condition,  such  as  suppuration  in  the  vestibule  or  in 
the  interior  of  the  nose."2 

Sinusitis.  Sinusitis  has  already  been  referred  to 
in  connection  with  rhinitis  sicca.  But  there  are 
some  further  circular  reactions  met  with  in  this 
disease.  Owing  to  the  narrowness  of  the  ducts 
draining  the  sinuses,  any  catarrhal  congestion  readily 
leads  to  obstruction,  followed  by  retention  and 
putrefaction  of  the  secretions,  paralysis  of  the  cilia 
and  further  retention.3  Moreover  the  growing  irri- 
tation may  steadily  increase  the  obstruction  until  this 
becomes  complete  (flMatC  X.  d). 

lArchiv  f.  Laryngologie  und  Rhinologie,  1896,  IV.,  p.  314. 
Cf.  also  Cartaz,  Castez  and  Barbier,  Maladies  du 
Nez  et  du  Larynx,  p.  34. 

2  Nasal  Suppuration,  tr.  by  Lamb.  p.  180. 

3 Under  the  name  "Vicious  Circle"  of  the  nose  Ballenger 
describes  and  illustrates  an  area  in  which  the  ostei 
of  the  posterior  ethmoidal  and  sphenoidal  sinuses 
drain  into  the  superior  meatus  above  the  middle 
turbinate,  while  the  frontal,  anterior  ethmoidal 
and  auxiliary  sinuses  drain  into  the  middle  meatus 
beneath  the  turbinates.  This  use  of  the  term 
"  Vicious  Circle "  is,  of  course,  entirely  distinct 
from  that  employed  in  this  volume.  Diseases  of  the 
Nose,  Throat  and  Ear,  pp.  118,  199,  202  f. 


Dicious  Circles  in  Disease 


Kuhnt  thus  describes  the  condition  as  met  with  in 
the  frontal  sinus  ;  it  may  serve  as  a  type  of  other 
forms  of  sinusitis  : 

"  In  cases  of  rhinitis  it  is  quite  possible  for  an  inde- 
pendent disorder  to  be  set  up  in  the  frontal  sinus,  which 
may  last  long  after  the  rhinitis  has  subsided.  The 
mucous,  muco-purulent  or  purulent  secretions  are 
either  unable  to  escape  or  only  do  imperfectly.  They 
are  then  apt  to  decompose,  and  in  their  turn  accentuate 
the  irritation  of  the  mucosa.  Bven  anatomical  changes 
frequently  result,  especially  in  the  naso-frontal  duct, 
close  the  Vicious  Circle,  and  thus  prevent  any  prob- 
ability, or  even  possibility,  of  a  natural  recovery."1 

Another  aggravating  factor  may  be  present  in 
purulent  sinusitis,  being  due  to  the  destruction  of  the 
ciliated  epithelium.  The  aggregate  effect  of  millions 
of  cilia  in  removing  the  secretions,  especially  when 
working  in  opposition  to  gravity,  must  be  of  great 
importance.  Acute  inflammation,  however,  and 
especially  the  retention  of  pus  rapidly  destroy 
ciliated  epithelium,  and  thus  neutralise  Nature's 
scavenging  provisions.  Retention  leads  to  retention. 

Polypus.  The  growth  of  a  polypus  seems  fre- 
quently to  be  due  to  persistent  irritation  caused  by 
suppuration,  which  is  then  kept  up  by  the  presence 
of  the  polypus  (JMate  X.  e).  The  same  reciprocity 
has  been  observed  in  other  parts  of  the  body  such  as 
the  ear  and  the  larynx. 

Heymann  writes  : 

"  The  polypus  irritates  the  adjacent  structures,  and 
thus  excites,  as  well  as  maintains,  a  condition  of 
inflammation.  In  saying  this  we  adopt  the  view  that 
a  polypus  may  owe  its  origin  to  a  condition  of  inflam- 
mation, so  that  a  form  of  circulus  vitiosus  is  established. 
....  In  many,  probably  most,  cases  suppuration 

1  Heymann,   Handbuch  der  I/aryngologie  und  Rhinologie, 
HI.,  P-  361. 


IRose  199 


has  started  and  led  to  the  formation  of  the  polypus  ; 
at  the  same  time  the  irritation  of  the  polypus  may 
cause  or  at  least  keep  up  the  suppuration.  It  is 
scarcely  necessary  to  add  that  the  continual  bathing 
of  the  mucosa  in  pus  may  in  turn  give  rise  to  fresh 
polypi."1 

The  increase  in  size  of  a  polypus  when  once  formed 
has  been  attributed  to  gravitation,  to  the  kinking  of 
the  blood-vessels,  to  the  traction  caused  by  blowing 
the  nose,  and  to  a  to-and-fro  movement  of  the 
polypus  due  to  respiration.  It  seems  at  any  rate 
possible  that  these  factors  may  accelerate  growth, 
and  the  larger  the  growth,  the  more  effectual  will 
these  factors  be. 

McKenzie  thus  refers  to  the  action  of  gravity  on 
the  growth  of  a  polypus  : 

"  It  is  partly  to  the  influence  of  gravity  that  we  may 
attribute  the  liability  of  the  lower  border  of  the  middle 
turbinal  to  polypi,  for  this  area,  hanging  as  it  does  free 
and  unsupported  over  the  middle  meatus,  will,  when  it 
becomes  oedematous,  sag  and  bag  so  that  a  bulging  of 
certain  limited  portions  will  occur.  And  so  polypoid 
excrescences  will  form.  Further,  the  return  circulation 
from  these  excrescences  naturally  becomes  more  and 
more  difficult  as  their  bulk  increases.  In  this  way  a 
Vicious  Circle  is  formed,  and  the  size  of  a  polypus  is 
limited  by  the  capacity  of  the  space  around  it,  and  not 
by  any  natural  tendency  to  stop  growing."2 

Rhinolith.  The  formation  of  concretions  and 
calculi  in  the  body  is  dependent  on  reciprocal 
reactions  between  the  primary  nucleus  and  the 
subjacent  mucosa,  and  the  same  principle  applies  to 

1  Handbuch  der  Laryngologie  und  Rhinologie,  III.,  p.  824. 

Cf .  also  Stoerk,  Erkrankungen  der  Nase,  des  Rachens 
und  des    Kehlkopfes  (Nothnagel's    Pathologic  und 

Therapie),  p.   188. 
'"Practitioiwr,  1910,  II.,  p.  186. 


200         IDidoue  Circles  in  Disease 

the  rhinoliths  occasionally  met  with  (plate  X.  f). 
The  nucleus,  whether  consisting  of  a  foreign  body,  of 
blood  or  of  mucus,  becomes  encrusted  with  salts 
derived  from  the  nasal  secretions,  and  in  turn 
acts  as  a  source  of  irritation  to  the  mucosa.  The 
greater  the  irritation  the  more  abundant  the  secre- 
tions and  the  more  rapidly  does  the  concretion  grow. 
In  some  cases  the  nares  may  be  completely  blocked. 

Rhinitis.  Some  attacks  of  nasal  catarrh,  even 
after  recovery,  greatly  diminish  the  resistance  of 
the  nasal  mucosa,  a  condition  which  shows  itself 
by  increased  liability  to  catarrh,  and  each  attack 
leaves  the  nose  more  predisposed,  in  fact  a  locus 
minor  is  resistentice.  A  similar  condition  is  associated 
with  the  various  nasal  neuroses,  and  depends  on  the 
principle  that  a  reflex  disturbance  once  produced  is 
so  much  the  more  easily  renewed.  Every  attack 
appears  to  diminish  the  control  of  the  nerve 
centres  and  to  induce  an  attack  on  less  and 
less  provocation. 

A  good  illustration  is  met  with  in  hay  fever,  a 
paroxysmal  neurosis  which  is  especially  liable  to 
attack  susceptible  persons  when  exposed  to  certain 
kinds  of  pollen  or  effluvia.  Each  attack  makes  the 
individual  more  susceptible  to  the  subtle  influence 
of  pollen  grains,  and  increases  the  probability  of 
fresh  seizures.1  In  other  sufferers  from  hay  fever 
the  idiosyncratic  hyperaesthesia  of  the  nasal  mucosa 
seems  to  provoke  an  inflammatory  hyperplasia  of 
the  affected  membrane,  which  hyperplasia  then 
renders  the  mucosa  even  more  sensitive  to  the 
noxious  agent  than  before.  Thus  cause  and  effect 
abet  each  other.  This  injurious  sequence,  however, 
is  by  no  means  constant. 


1  Quain,  Dictionary  of  Medicine,  I.,  p.  786. 


Chapter  twelve 


THE   THROAT 

ISEASES  of  the  throat  may  be  compli- 
cated by  some  circular  reactions  of  great 
clinical  importance. 

Diphtheria.  The  throat  is  the  favour- 
ite seat  of  diphtheria,  a  virulent  disease 
whose  tendency  to  extension  depends  on  the  patho- 
logical changes  which  take  place  in  mucous  mem- 
branes when  invaded  by  the  Klebs-Ix>ffler  bacillus 
(JMatC  XI.  a).  These  changes  vary  in  different 
cases.  Sometimes  a  definite  membrane  is  formed  ; 
in  other  cases  there  is  merely  a  delicate  network  of 
fibrin  enclosing  leucocytes,  red  corpuscles  and  bac- 
teria. To  these  conditions  are  superadded  stasis 
and  exudation  in  the  mucous  membrane,  portions  of 
which  may  even  be  necrosed.  These  local  effects  of 
the  bacilli  and  their  toxins  injure  the  neighbouring 
tissues  in  such  a  way  that  a  favourable  culture- 
medium  is  prepared  for  the  proliferation  of  the 
bacilli  and  the  increase  of  their  toxins  which  then 
enter  the  blood.  Hence  it  is  that  the  morbid  process 
tends  to  extend  so  rapidly,  both  superficially  and  in 
depth.  Lowered  resistance  favours  extension  of  the 
evil  and  vice  versa. 

(Edema  of  Aryteno-Epiglottidean  Folds.     In 

cases  of  congestion  of  the  aryteno-epiglottidean  folds 
the  two  cedematous  swellings  may  be  seen  lying  like 

201 


202 IPictoug  Circles  in  Disease 

valves  above  the  glottis.  There  is  then  a  risk  that 
they  may  be  sucked  together  during  inspiration  and 
provoke  acute  dyspnoea.  The  greater  the  dyspnoea 
the  greater  the  inspiratory  efforts  and  the  more 
closely  do  the  cedematous  folds  approximate,  death 
sometimes  resulting  from  suffocation. 

Tongue-Swallowing.  Death  may  also  result  from 
tongue-swallowing,  a  rare  accident  in  children  whose 
fraenum  is  too  long  or  has  been  divided.  The  danger 
arises  from  the  tongue  being  so  retracted  into  the 
pharynx  at  the  time  of  deglutition  as  to  hinder 
the  entrance  of  air  during  inspiration.  The  conse- 
quent dyspnoea  is  apt  to  lead  to  further  retraction  ; 
the  tongue  may  even  come  to  be  fixed  in  the  gullet 
like  a  wedge,  obstructing  the  larynx  so  completely 
that  no  air  can  reach  the  lungs.  Several  cases  of 
asphyxia  due  to  this  condition  are  on  record.1 

Laryngitis.  laryngitis  is  frequently  a  self-per- 
petuating condition  through  its  effects  reacting  on 
their  cause.  For  example,  congestion  and  erosion 
of  the  cords  provoke  severe  paroxysms  of  coughing. 
The  inflamed  surfaces  are  brought  into  violent 
contact,  and  this  in  turn  aggravates  the  mischief. 

The  accumulation  of  adhesive  secretions  is  another 
source  of  irritation,  which  is  accentuated  by  the 
constant  efforts  that  are  made  to  clear  the  throat. 
The  secretions  also  interfere  with  the  repair  of  an 
inflamed  mucosa  or  of  an  ulcer,  an  injurious  reci- 
procation being  maintained  in  all  these  ways.  Even 
hoarseness  does  harm  by  the  increased  effort  involved 
in  the  act  of  speaking  or  singing.  The  greater  the 
effort  the  more  does  the  laryngeal  congestion  increase. 


1An  illustration  shewing  how  readily  such  asphyxia  may 
be  brought  about  is  given  by  Hare,  Practical  Thera- 
peutics, p.  670. 


ftbroat 


203 


(a)  DIPHTHERIA 


'^ 


(c)  ABDUCTOR  PARALYSIS 


uo\V 

(b)  POLYPUS 


,^ 

/>  S     ^\°* 

to 

1      to 


G" 
* 
t 
^       J 

^^^^  5u\^   o^ 
p\6^ 


(d)  STAMMERING 


(e)  GOITRE 


(f)  ENLARGED  THYMUS 


plate  xi.— Circles  aseociatefc  with  the 
Gbroat. 


204 IDtdoug  Circles  in  %)t0ease 

Injurious  correlations  also  occur  in  tubercular 
laryngitis  owing  to  the  associated  cough,  vomiting 
and  dysphagia.  In  consequence  of  the  irritability  of 
the  larynx  the  cough  may  be  incessant,  and  rob  the 
sufferer  of  the  sleep  and  laryngeal  rest  which  are  so 
essential  if  the  progress  of  the  disease  is  to  be  checked. 
The  cough  may  also  be  accompanied  by  frequent 
vomiting  so  that  an  insufficient  amount  of  food  is 
retained.  The  resulting  malnutrition  diminishes  the 
power  of  resistance  and  accelerates  the  disease. 
Again  when  the  epiglottis  is  invaded  by  tubercular 
deposits  there  is  often  acute  pain  on  deglutition,  and 
the  suffering  and  dysphagia  may  cause  the  refusal  of 
all  food,  however  appetising.  The  victim  is  in  as 
grievous  a  predicament  as  Tantalus  of  old  ;  emaci- 
ation and  aggravation  inevitably  result. 

In  patients  in  whom  there  is  an  exaggerated  reflex 
susceptibility  of  the  nervous  system,  excessive  cough 
may  so  irritate  and  exhaust  the  medullary  centre  as 
to  pervert  the  reflex  mechanism.  The  cough  be- 
comes uncontrollable  and  persists  even  though  all 
local  irritation  has  subsided. 

Chronic  laryngitis  is  frequently  associated  with  the 
formation  of  neoplasms,  each  disorder  favouring  the 
other.  The  sequence  of  events  is  much  the  same 
as  those  occurring  in  the  nose  and  the  ear  (platC 
XI.  b).  Sometimes  a  pedunculated  growth  may  be 
sucked  into  the  glottis  so  as  to  provoke  urgent 
dyspnoea,  followed  by  increased  impaction  and 
death. 

Schrotter  writes  : 

"  Chronic  catarrh  is  very  frequently  associated  with 
new  growths  in  the  larynx,  a  Vicious  Circle  being 
clearly  present.  The  catarrh  leads  to  the  formation 
of  the  neoplasm  and  this,  especially  if  pedunculated, 
keeps  up  the  catarrh."1 

^orlesungen  iiber  die  Krankheiten  des  Kehlkopfes,  p.  66. 


ftbroat  205 


Chronic  laryngitis  presents  an  illustration  of  that 
condition  in  which  primary  disease  leaves  behind 
it  a  diminished  resistance  to  fresh  attack,  a  liability 
to  recrudescence  on  the  slighest  exposure.  There 
is  no  permanent  restitutio  ad  integrum,  and  each 
attack  may  end  in  an  increase  of  mischief. 

Laryngismus  Stridulus.  According  to  various 
writers  the  respiratory  glottic  spasm  of  laryngismus 
stridulus  may  be  a  self-perpetuating  condition  owing 
to  the  increasing  venosity  of  the  blood  due  to  the 
spasms. 

The  spasms  are  supposed  to  cause  venosity,  which 
venosity  induces  fresh  spasms  which  occasionally 
prove  fatal. 

This  view  was  held  by  Charles  West  : 

"  When  once  convulsions  have  occurred,  a  new 
element  soon  comes  into  play,  which  aggravates  the 
danger  and  increases  the  frequency  of  an  attack.  The 
blood,  imperfectly  depurated,  if  the  disturbance  of 
respiration  has  been  considerable,  seems  in  itself  to 
exercise  an  injurious  influence,  by  increasing  the 
irritability  of  the  nervous  system  and  thus  promoting 
the  return  of  the  attack.  If  once  convulsions  have 
occurred,  the  probability  of  their  recurrence  is  much 
increased  ;  and  the  oftener  they  have  happened,  the 
more  often  are  they  likely  to  return,  and  the  graver  is 
the  prognosis  which  you  are  compelled  to  form.  This 
rule  holds  good,  too,  not  only  with  reference  merely 
to  spasmodic  croup,  but  with  reference  to  all  spasmodic 
affections  of  the  respiratory  organs,  and  whooping 
cough  affords  one  of  its  best  exemplifications.  In 
some  fit  of  coughing  more  violent  than  any  of  the  others, 
the  spasm  of  the  larynx  is  of  longer  continuance,  the 
face  grows  livid,  a  fruitless  expiratory  effort  is  made, 
and  before  the  spasm  relaxes  a  convulsion  takes  place. 
This  convulsion  is  but  very  seldom  a  solitary  one. 
You  notice  that  for  hours  it  is  succeeded  by  very 
accelerated  breathing  ;  by  which,  however,  the  blood 
is  very  imperfectly  depurated,  as  you  see  by  the  lips 
which  never  resume  their  natural  colour.  At  length 


206  IDidous  Circles  in  disease 

the   disturbance   once  more   reaches   its  climax,    and 

another,    and  then    another    convulsion  occurs,  with 

a    gradually-diminishing    interval,   until  death    takes 
place."1 

Hughlings  Jackson  held  similar  views  : 

"  Great  venosity  of  the  blood  will  much  over- 
stimulate  the  naturally  very  excitable  respiratory 
centres  in  infants,'  and  thus  produce  respiratory  con- 
vulsions. When  there  has  been  first  set  up  any  degree 
of  spasm  of  any  part  of  the  respiratory  apparatus,  the 
venosity  will  become  greater  still,  and  thus  there  will 
be  a  rapid  multiplication  of  effects.  In  other  words 
a  Vicious  Circle  is  established.  Super- venosity  initiates 
the  paroxysm,  which  increases  the  super-venosity."2 

This  theory  is,  however,  by  no  means  generally 
accepted.  In  many  cases  the  increased  venosity 
seems  to  arrest  rather  than  prolong  the  convul- 
sions. 

Another  form  of  spasmodic  closure  of  the  larynx 
is  sometimes  observed  in  cases  of  reflex  rigidity 
caused  by  a  surgical  operation.  This  may  also 
be  a  self-perpetuating  condition,  as  Mortimer  points 
out  : 

"  Reflex  rigidity  from  surgical  proceedings  is  accom- 
panied by  more  or  less  spasmodic  closure  of  the  larynx 
and  retraction  of  the  tongue,  and  efforts  must  be  made 
to  maintain  a  free  air-way  by  such  means  as  pushing 
forward  the  tongue,  and  introducing  a  tube  between 
the  tongue  and  palate.  Non- aeration  increases  rigidity, 
the  extraordinary  respiratory  muscles  being  called 
into  action,  so  that  a  Vicious  Circle  is  formed."3 

Paralysis  of  the  Abductors.  A  deadly  vortex 
may  be  set  up  in  connection  with  paralysis  of  the 
abductors,  i.e.  the  posterior  crico-arytenoid  muscles 
(JMatC  XI.  c).  In  normal  respiration  the  glottis 

1  Medical  Times,  XIX.,  p.  522. 

2  Brain,  IX.,  pp.  14,  15  ;    XII.,  p.  4gi. 

3  St.  Bartholomew's  Hospital  /.,  1917,  I.,  p.  89. 


Gbe  Gbroat  207 


dilates  with  every  inspiration,  and  the  deeper  the 
inspiration  the  wider  the  glottis.  When,  however, 
the  abductors  are  paralysed,  inspiration  is  no  longer 
assisted  by  dilatation  of  the  glottis,  but,  on  the 
contrary,  is  impeded  by  increased  approximation 
of  the  cords,  which  are  separated  by  a  mere  chink. 
The  narrowing  of  the  glottis  provokes  dyspnoea  and 
the  dyspnoea  leads  to  further  narrowing.  A  sufferer 
from  bilateral  posticus  paralysis  has  a  sword  of 
Damocles  hanging  over  him. 

Stammering.  Exaggerated  self -consciousness 
and  stammering  are  frequently  correlated  (JMatC 
XI.  d).  Many  persons  stammer  but  slightly  when 
perfectly  at  ease.  But  any  mental  perturbation  at 
once  aggravates  their  disability,  and  this  aggrava- 
tion in  turn  intensifies  their  perturbation.  The 
stutterer  stutters  most  when  he  is  trying  hardest 
to  avoid  stuttering. 

Another  neurosis  is  associated  with  the  globus 
hystericus,  the  sensation  of  a  lump  that  rises  in  the 
throat  and  is  probably  due  to  pharyngeal  spasm. 
The  disorder  is  one  that  occurs  in  sensitive  intro- 
spective persons  and  in  its  turn  excites  auto- 
suggestions. 

Tracheal  Stenosis.  Dangerous  correlations  may 
occur  in  cases  of  enlarged  thyroid,  where  this  gland 
compresses  the  trachea  and  reduces  the  lumen  to  a 
slit  ;  acute  and  sometimes  fatal  attacks  of  dyspnoea 
are  liable  to  come  on  quite  unexpectedly  (platC  XI.e). 
Started,  perhaps,  by  some  casual  effort,  the  dyspnoea 
calls  the  supplementary  respiratory  muscles  (especi- 
ally the  sterno-hyoids  and  -thyroids)  into  action. 
These  in  contracting  press  the  hypertrophied  thyroid 
against  the  trachea,  further  diminish  the  lumen  and 
so  increase  the  dyspnoea.  Thus  the  victim  is  caught 
in  a  dangerous  sequence,  and  unless  skilled  help  is 
promptly  given,  dies  miserably  self-garotted.  The 


208          iDidous  Circles  in  Disease 

very  mechanism  devised  for  increasing  the  supply 
of  air  through  the  narrowed  trachea  aggravates  the 
stenosis. 

Frankel  writes  : 

"  The  sufferer  gets  into  the  clutches  of  a  Vicious 
Circle.  The  greater  the  want  of  oxygen,  the  more 
vigorous  and  prolonged  the  muscular  contractions  ; 
the  more  vigorous  the  latter,  the  greater  the  compression 
of  the  trachea  and  the  less  room  for  the  admission  of 
air."1 

A  goitre  is  also  liable  to  press  on  or  stretch  nerves 
which  reflexly  produce  respiratory  spasm.;  this 
then  leads  to  further  pressure. 

Again  the  heightened  blood-pressure  produced 
during  expiration  raises  the  pressure  in  the  extensive 
plexus  of  veins  that  encircle  the  thyroid  gland.  In 
this  way  increased  swelling  of  the  goitre  is  brought 
about,  and  the  stenosis  is  aggravated.  Venous 
haemorrhage  into  adenomatous  cysts  may  also  set 
up  morbid  correlations.  The  increased  pressure  on 
the  trachea  leads  to  dyspnoea,  to  over-filling  of  the 
right  heart,  and  to  congestion  of  the  veins  of  the 
neck.  This  congestion  in  turn  aggravates  the 
haemorrhage. 

Similar  complications  follow,  when,  instead  of  the 
trachea  being  compressed  from  without,  there  is  endo- 
tracheal  stenosis,  due  to  syphilis  or  a  new  growth. 
The  stenosis  brings  on  dyspnoea  and  increased 
activity  of  the  respiratory  muscles.  This  causes  an 
overfilling  of  the  right  side  of  the  heart  during 
inspiration  owing  to  the  increased  suction  action. 
During  expiration,  on  the  other  hand,  the  high 
intra-thoracic  pressure  exerted  on  the  lungs  hinders 
the  entry  of  the  blood  into  the  lungs,  and  the  effect 
of  this  is  further  to  increase  dyspnoea. 

1  lyungenkrankheiten,  p.  8.     Cf.    also   Jacobson   and    Row- 
lands, Operations  of  Surgery,  I.,  p.  6ro. 


209 


Frankel  writes  : 

"  Any  condition  which  accelerates  the  venous  flow 
on  the  right  side  of  the  heart  must  under  such  circum- 
stances aggravate  the  state  of  the  patient.  This 
applies  especially  to  increased  muscular  activity,  and 
to  the  increased  dyspnoea  necessarily  associated  with  it. 
A  circulus  vitiosus  is  thus  established  as  a  result  of  the 
increased  respiratory  activity."1 

Enlarged  Thymus.  A  fatal  process  of  recipro- 
cation is  occasionally  associated  with  thymic  enlarge- 
ment, owing  to  the  readiness  with  which  any  hyper- 
plasia  of  the  gland  causes  pressure  on  the  trachea 
and  dyspnoea  (gMatC  XI.  f). 

The  normal  thymus  weighs  about  6  grms.,  but 
in  cases  of  lymphatism  the  weight  may  rise  to  50 
grms.  or  even  more.  In  early  Hfe  the  interval  be- 
tween the  manubrium  and  the  spinal  column  only 
measures  2.5-3  cm.,  so  that  even  a  moderate  hyper- 
plasia  may  produce  tracheal  stenosis  and  conse- 
quent dyspnoea.  Such  dyspnoea  in  turn  leads  to 
venous  engorgement  and  further  enlargement  of  the 
thymus,  thus  setting  up  a  "  Vicious  Circle  that  may 
quickly  lead  to  suffocation."2 

Mutism.  In  cases  of  shock,  such  as  that  due  to 
the  high  explosives  used  in  modern  warfare,  various 
nervous  disorders  have  been  met  with  due  to  a 
suspension  of  the  connection  between  the  peripheral 
impulses  and  the  higher  cortical  centres  of  the 
nervous  system.  The  victim  may  be  so  convinced 
that  he  is  mute  that  he  actually  becomes  so 
through  auto-suggestion,  and  makes  no  attempt 
to  speak.  Suggestion  sometimes  succeeds  in  switch- 
ing on  the  interrupted  synapses  between  the  vocal 
organs  and  the  cerebral  cortex  and  thereby  restores 
the  power  of  speech.  Parallel  conditions  have  been 
described  in  connection  with  vision  and  hearing. 

1  Lungenkrankheiten,  p.  29. 

-  Osier  and  Macrae,  System  of  Medicine,  IV.,  p.  926. 


Chapter  thirteen 


THE   EAR 

OR  the  purpose  of  description  the  ear 
is  divided  into  three  parts  :  external, 
middle  and  internal.  Injurious  circular 
reactions  associated  with  the  ear  may 
be  arranged  in  the  same  divisions. 


I.    THE   EXTERNAL   EAR 

The  external  ear  is  liable  to  various  inflammatory 
conditions  which  may  be  self -perpetuating. 

Otitis  Externa.  Simple  otitis  externa  gives  rise 
to  unhealthy  secretions  which  if  allowed  to  stagnate 
in  the  meatus  set  up  irritation  and  congestion,  which 
excite  further  secretion  and  accumulation.  This 
complication  is  especially  common  if  the  canal  is 
narrowed,  since  the  tendency  to  retention  is  thus 
increased. 

In  some  inflammatory  conditions  mycotic  infection 
may  be  present,  due  to  the  spores  and  mycelium  of 
the  aspergillus  niger  or  other  fungus.  The  parasite 
nourished  by  the  secretions  penetrates  beneath  the 
epidermis  and  excites  further  inflammation.  Indeed 
the  disease  largely  depends  on  the  fact  that  the 
fungus  increases  the  discharge  and  thus  promotes  its 
own  growth. 

The  skin  of  the  meatus  may  also  be  the  seat  of 
an  infective  disorder,  when  one  or  more  hair-follicles 

210 


Gbe  Ear  211 


are  invaded  by  staphylococci.  The  invasion  is 
generally  accompanied  by  itching,  which  leads  to 
scratching,  abrasion  and  fresh  inoculation.  The 
succession  of  boils  so  often  observed  is  usually  due 
to  auto-inoculation  caused  by  scratching. 

Another  common  inflammatory  disorder  is  eczema 
which  is  frequently  complicated  by  pruritus.     This 
pruritus    leads    to    scratching    which    perpetuates 
the  trouble. 
Guisez  writes  : 

"  Eczema  of  the  meatus  is  always  associated  with 
very  severe  itching,  which  obliges  the  sufferer  to 
scratch.  The  resulting  abrasions  perpetuate  the  inflam- 
mation of  the  epidermis  and  thus  prevent  recovery."1 

The  formation  of  crusts  also  tends  to  prolong 
the  disease  by  retaining  secretions  which  are  liable 
to  become  infected.  Such  infection  aggravates  the 
irritation  and  inflammation  of  the  subjacent  tissues. 

Accumulation  of  Cerumen.  Occasionally  per- 
sons are  met  with  who  suffer  from  an  excessive 
secretion  of  cerumen  due  to  hyperaemia  of  the  lining 
membrane  (]MatC  XII.  a).  A  laminated  epithelial 
plug  may  thus  be  formed  composed  of  the  horny 
layer  of  the  cutis  of  the  auditory  canal.  Such  a 
plug  if  allowed  to  remain  in  situ  excites  further 
irritation  and  hypersemia,  and  stimulates  the  glands 
to  abnormal  activity. 

II.     THE    MIDDLE    EAR 

Otitis  Media.  A  serious  self-perpetuating  con- 
dition arises  when,  as  a  result  of  Eustachian  obstruc- 
tion, inflammatory  discharges  are  pent  up  in  the 
tympanum  and  undergo  putrefaction,  forming  indeed 
a  septic  tank.  Such  discharges  irritate  the  mucous 
lining  of  the  cavity  and  excite  further  discharge 
which  aggravates  the  disease  (jplatC  XII.  b). 

1  La   Pratique   Oto-Rhino-Laryngologique,   III.,   p.   83. 


212  tDicious  Circles  in  2>i0eaee 


Again  the  accumulation  of  inflammatory  products 
in  the  tympanum  exerts  pressure  on  the  superficial 
veins  and  lymphatics  and  blocks  the  natural  channels 
of  absorption.  Such  closure  leads  to  increased 
accumulation  and  increased  pressure. 

The  destruction  of  ciliated  epithelium  by  pus  is 
another  source  of  injurious  correlations.  During 
health  the  movements  of  the  cilia  are  directed  to- 
wards the  pharynx  and  assist  in  clearing  the 
tympanum  of  epithelial  or  other  detritus.  Retained 
pus,  however,  destroys  this  epithelium  and  abolishes 
the  scavenging  mechanism.  Retention  leads  to 
retention. 

A  similar  sequence  may  involve  the  accessory 
cavities  of  the  tympanum,  viz.  the  antrum  and 
mastoid  cells.  Indeed  the  conformation  of  the 
temporal  bone,  with  its  warm  and  moist  cavities 
and  the  awkwardly  situated  efferent  ducts,  greatly 
favours  the  imprisonment  and  putrefaction  of  inflam- 
matory and  other  debris,  the  narrow  communicating 
channels  being  readily  obstructed  and  blocked. 

Chronic  catarrhal  otitis  associated  with  Eustachian 
obstruction  is  often  complicated  by  rarefaction  of 
the  air  in  the  tympanic  cavity  due  to  a  process 
of  absorption.  The  result  is  that  the  drum  mem- 
brane is  gradually  stretched  and  eventually  conies 
to  lie  against  the  internal  wall  of  the  tympanum, 
thus  maintaining  the  otitis. 

Bench   writes  : 

"  A  gradual  stretching  of  the  drum  membrane 
takes  place  from  the  continued  pressure  from  with- 
out, until  finally  further  displacement  is  prevented 
by  contact  with  the  internal  tympanic  wall.  The 
pressure  against  this  resisting  barrier  increases  the 
local  inflammatory  process.  The  movement  of  the 
drum  membrane  inward  and  its  persistence  in  this 
position  is  favoured  by  the  action  of  the  tensor 
tympani  muscle,  which  by  contraction  draws  the 


She  £ar 


213 


(a)  ACCUMULATION  OF  CERUMEN 


.(b)  OTITIS  MEDIA 


(f)  AUTO-SUGGESTED  DEAFNESS 


plate  XII.— Circles  aesoctateb  with 
tbe    Ear, 


214         IDtctoug  Circles  in  ^Disease 

membrane  inward  against  the  wall  of  the  middle 
ear.  From  disuse  the  tendon  becomes  shortened, 
this  change  being  aided  by  the  inflammatory  process."1 

An  occasional  consequence  of  purulent  otitis 
media  is  the  formation  of  a  cholesteatoma,  consisting 
of  inspissated  pus  mixed  with  exfoliated  epithelial 
cells  ((Mate  XII.  c).  The  constant  friction  of  this 
mass  irritates  the  enclosing  walls  and  provokes  a 
continual  proliferation  and  desquamation  of  cells, 
which  in  turn  become  adherent  to  the  mass  and  so 
add  layer  to  layer.  The  cholesteatoma  thus  increases 
much  as  does  a  vesical  or  a  biliary  calculus,  irritation 
leading  to  growth  and  growth  to  increased  irritation. 
The  mass  may  in  time  reach  the  size  of  a  walnut, 
and  produce  grave  or  even  fatal  results  by  invading 
the  labyrinth  or  cranial  cavity.2 

Polypus.  Aural  polypus  may  be  associated  with 
similar  morbid  correlations  to  those  observed  in 
connection  with  the  nose.  In  some  cases  at  any 
rate  an  aural  polypus  appears  to  result  from,  as 
well  as  to  perpetuate,  suppuration. 

Cradle  writes  : 

"  Well- ascertained  histories  often  teach  that  polypi 
are  started  by  prior  suppurative  disease,  which  their 
presence  then  serves  to  perpetuate."3 

Deafness.  Deafness  may  itself  tend  to  further 
deafness  by  preventing  the  accurate  adjustment  of 
the  tensor  tympani  to  the  vibrations  of  sound  that 
reach  the  drum,  and  thus  making  it  difficult  to  give 
the  attention  necessary  for  good  hearing. 


Diseases  of  the  Ear,  pp.  310,  360. 

-  Denker  and  Briinings,   Krankheiten  des  Ohres  und  der 

Luftwege,  p.  125. 
3  Diseases   of  the  Nose,  Pharynx   and  Ear,  p.  1910.     This 

quotation  applies  to  the  ear  as  much  as  to  the  nose. 


215 


Urbantschitsch  writes  : 

"  Impaired  hearing  is  aggravated  by  inadequate 
auditory  stimulation,  by  inattention  as  well  as  by 
inability  to  participate  in  social  life.  Hence  a  para- 
lysing isolation  envelops  the  hard-hearing  person 
more  and  more  closely.  Systematic  auditory  exercises 
are  obviously  of  great  importance."1 

Deafness  may  also  be  aggravated  when  persons 
suffering  from  relaxation  of  the  drum  and  associated 
disorders  of  the  ossicles  and  labyrinthine  window 
endeavour  to  improve  their  hearing  by  continually 
inflating  the  tympanum.  Some  sufferers  use  the 
Valsalvan  method  of  inflation,  others  blow  their 
nose  in  order  to  force  air  into  the  Eustachian  tube. 
Although  there  may  be  a  temporary  improvement 
as  a  result  of  this  nanoeuvre,  its  constant  repetition 
leads  to  further  stretching  of  the  membrane,  the 
loose  folds  of  which  come  to  rest  on  the  inner 
tympanic  wall  and  incudo-stapedial  articulation. 
The  deafness  is  thus  permanently  increased  through 
the  operation  of  an  artificial  Circle. 

Heath  writes  : 

"  The  constant  distension  of  the  tympanum  with 
air  must  increase  the  relaxation  of  the  weakened 
tympanic  structures,  and  this  allows  of  a  further 
unopposed  muscular  stretching  of  the  labyrinthine 
window,  thus  aggravating  the  condition  which  is  the 
essential  cause  of  the  deafness."2 

After  an  attack  of  otitis  media  the  middle  ear 
often  remains  a  locus  minoris  resistentiw.  The 
incompleteness  of  recovery  is  shown  by  a 
disposition  to  relapse,  by  a  diminished  resistance  to 
fresh  disease,  and  with  every  attack  the  permanent 

1  Deutsche  Klinik,  VIII.,  p.  274. 

2  The  Treatment  of  Deafness  (Paracusis  Willissii),  p.  64.  Cf. 

also  Politzer,  Diseases  of  the  Ear,  pp.  142,  198,  342. 


216          IDicious  Circles  in  Biseaee 

lesion  increases  until  the  cumulative  mischief  may  be 
very  extensive. 

An  allied  condition  may  be  met  with  when 
serious  and  debilitating  illness  has  greatly  lowered 
the  resistance  of  the  organism  to  pathogenic  influ- 
ences. During  health  a  great  variety  of  micro- 
organisms are  present  in  the  normal  mucosa  of 
the  tympanum  without  causing  any  symptoms. 
If,  however,  prolonged  pyrexia  or  other  drain  on  the 
system  lowers  resistance  and  renders  the  tissues 
more  vulnerable,  the  pathogenic  microbes  may 
become  active  and  virulent.  For  example,  a  suppur- 
ating ear  may  produce  a  lowered  state  of  health  ; 
such  ill  health  will  keep  up  the  suppuration  which 
would  cease  under  more  favourable  bodily  conditions. 
The  local  and  general  disorders  perpetuate  each 
other. 

III.     THE    INTERNAL   EAR 

Neuroses.  In  neuropaths  severe  tinnitus  may  be 
both  cause  and  effect  of  neurasthenia.  Acute 
torment  may  be  caused,  and  the  more  the  mind 
is  concentrated  on  the  disorder  the  more  is  the 
sufferer  harassed.  Even  men  of  strong  nervous 
temperament  have  been  so  grievously  obsessed  by 
noises  in  the  head  as  occasionally  to  commit  suicide. 
A  somewhat  similar  condition  arises,  when  the 
persistent  otalgia  that  complicates  some  forms  of 
aural  disease  induces  hyperaesthesia  and  neurasthenia, 
especially  if  insomnia  is  superadded  (JMatC  XII. 
d,  e). 

Even  apart  from  tinnitus  and  otalgia,  any  impair- 
ment of  hearing  power  is  likely  to  react  unfavour- 
ably on  neurasthenia,  owing  to  the  continued  aural 
strain  involved  in  the  effort  to  hear.  Such  strain  is 
a  constant  tax  on  the  reserves  of  nervous  energy. 
In  the  morning,  when  refreshed  by  a  night's  rest,  the 
patient  hears  fairly  well.  But  as  the  day  passes  the 


Ear  217 


nervous  system  becomes  over-taxed  and  he  loses  the 
power  of  concentrating  attention.  This  involves 
increased  deafness  and  increased  auditory  strain. 

Dench   writes  : 

"  After  being  subjected  to  the  fatigue  consequent 
on  the  day's  activity,  the  hearing  power  becomes  much 
diminished,  and  any  effort  on  the  part  of  the  patient 
to  disguise  the  symptom  simply  magnifies  it.  The 
local  impairment,  in  turn,  reacts  upon  the  general 
condition  of  the  patient  to  a  considerable  degree, 
frequently  causing  him  to  become  hypochondriac,  and 
in  some  cases  leading  to  acute  melancholia."1 

Many  forms  of  deafness  seem  to  impair  vitality, 
doubtless  owing  to  the  fewer  stimuli  that  reach 
the  sensorium.  This  is  frequently  observed  in  early 
life.  Deaf  children  lack  vitality  and  such  lessened 
vitality  increases  their  deafness. 

Auto-Suggestion.  Another  form  of  deafness  is 
due  to  auto-suggestion.  For  example,  after  the 
explosion  of  a  shell  a  soldier  may  be  convinced  that 
he  is  deaf  and  make  no  attempt  to  listen  (platC  XII.  f). 
The  aural  perceptive  structures  in  the  brain  may  be 
dissociated  from  the  nervous  tracts  which  convey 
the  peripheral  stimuli  from  the  ears,  so  that  sound 
vibrations  fail  to  produce  the  slightest  auditory 
sensations.  Suggestion  frequently  succeeds  in  restor- 
ing the  hearing  by  re-association,  by  switching  on 
the  interrupted  synapses. 

Hurst  writes  : 

"  The  momentary  deafness,  which  is  the  natural 
result  of  the  terrific  noise  caused  by  the  explosion  of  a 
big  shell  in  the  immediate  neighbourhood,  may  make 
such  an  impression  on  the  mind  of  a  soldier  that,  on 
coming  to  himself,  whether  he  has  actually  lost  con- 
sciousness or  not,  his  first  thought  is  for  his  hearing, 
especially  if  it  was  already  impaired  by  preceding 

Diseases  of  the  Ear,  p.  663. 


218         IDfcious  Circles  in  IDiseaee 

disease,  and  he  may  be  so  convinced  that  he  is  per- 
manently deafened  that  he  becomes  actually  deaf  as  a 
result  of  auto-suggestion.  Hearing  necessitates  listening. 
Inattention  during  a  dull  sermon  results  in  total 
deafness  to  the  sermon,  and  in  hysterical  deafness  the 
patient  is  so  convinced  that  he  cannot  hear  that  he 
does  not  listen  ;  although  the  sound  vibrations  reach 
the  ear  in  the  normal  way,  they  do  not  give  rise  to  the 
slightest'  auditory  sensation  because  of  this  inattention. 
The  synapses  at  one  or  more  of  the  cell-stations  in  the 
auditory  path  to  the  cerebral  cortex  must  therefore  be 
unswitched,  probably  as  a  result  of  retraction  of  the 
dendrons."1 

Vertigo.  Vertigo  is  another  aural  neurosis  which 
reacts  on  the  primary  disorder  and  so  perpetuates 
its  own  cause.  The  victim  may  lose  confidence  in 
himself  and  becomes  the  prey  of  phobias  which  feed 
the  neurosis. 

Bing  writes  : 

"  If  a  neurasthenic  has  once  experienced  a  subjective 
difficulty  of  this  sort  the  fear  of  vertigo  makes  itself 
felt  in  a  very  marked  form  and  the  recurrence  of  such 
symptoms  naturally  increases  this  fear — a  painful 
Vicious  Circle.  Fortunately  in  very  few  cases  does  an 
actual  permanent  vertigo  appear."2 


lProc.  Royal  S.  of  Med.  (1917),  X.  (iii.),  (Otology),  p.  115. 
2  Nervous    Diseases,    p.    412. 


Chapter  fourteen 


THE   SKIN 

HE    following    classification    of    disorders 
of  the  skin  will  be  found  convenient  : 

I.     Inflammatory  Disorders 
II.     Parasitic  Disorders 
III.     Disorders    associated   with   Append- 
ages   of    the    Skin — Hair,    Nails, 
Sweat  and  Sebaceous  Glands 
IV.     Neuroses 

I.     INFLAMMATORY    DISORDERS 

Eczema.  Eczema  will  serve  as  a  type  of  various 
disorders  which  are  self-perpetuating  through  the 
pruritus  which  they  excite  ((Mate  XIII.  a).  The 
itching  and  associated  scratching  aggravate,  and 
may  indefinitely  prolong,  the  lesion  that  produced 
them. 

McCall  Anderson,  speaking  of  acute  eczema, 
says  : 

"  Scratching  always  aggravates  the  disease  and 
tends  to  bring  out  fresh  crops  of  eruption.  .  .  .  Often 
in  mild  cases,  where  there  is  not  much  infiltration,  the 
disease  is  kept  up  by  the  scratching  alone."  l 

Similar  correlations  occur  in  chronic  eczema, 
as  Kaposi  points  out  : 

"  The  attendant  itching  is  generally  very  severe  and 
induces  violent  scratching.  This  acts  as  a  cutaneous 
irritant  and  may  excite  a  fresh  eczema."2 


Diseases  of  the  Skin,  p.    103. 
2  Diseases   of   the  Skin,   p.  345. 

219 


220 iDtctoug  Circles  in  gHecage 

When  scratching  has  been  indulged  in  over  a 
long  period,  the  skin  may  undergo  a  process  known 
as  lichenification,  characterised  by  the  presence  of 
pseudo-papules  and  accompanied  by  furious  itching 
due  to  irritation  of  the  nerve  endings  by  the 
dermatitis. 

Malcolm  Morris  writes  : 

"  The  itching  provokes  scratching,  the  scratching 
sets  up  lichenification  which  irritates  the  nerve  endings 
and  provokes  further  itching.  The  main  object  of 
treatment  is  to  break  this  Vicious  Circle  by  reducing 
the  lichenification  and  restoring  the  damaged  tissues 
to  the  normal  state."1 

Chronic  eczema  is  often  associated  with  varicose 
veins  and  ulcers  of  the  leg.  The  varices  give  rise 
to  itching  and  scratching,  as  a  result  of  which  papules, 
excoriations,  haemorrhages  and  crusts  are  produced. 
The  consequent  inflammation  and  itching  lead  to 
deeper  excoriations  and  increased  inflammation. 
Eventually  the  skin  breaks  down,  giving  rise  to  the 
well-known  varicose  ulcer. 
Kaposi  writes  : 

"  These  secondary  inflammatory  processes  aggravate, 
for  the  time,  the  local  exudation  and  congestion  and  are 
themselves,  again,  causes,  leading  to  the  destruction  of 
the  scarcely  reproduced  young  tissue,  that  is,  of 
the  granulations  and  cicatrices.  They  are,  therefore,  a 
source  of  ulceration,  at  the  same  time  that  originally 

they  resulted  from  it Such  a  condition  of  the 

skin  predisposes  in  a  high  degree,  per  se,  to  renewed 
attacks  of  inflammation  on  the  slightest  provocation  ; 
and,  since  the  inflammation  again  tends  to  maintain 
and  increase  the  ulceration,  we  have  here  an  endless 
circulus  vitiosus."* 

Varicose  ulcers  may  also  be  complicated  by  what 
Unna  terms  an  "  incurable  circulus  vitiosus  "  due  to 


1  British  Med.   /.,   1912,    I.,   p.    1472.      Cf.    also  Mraeek, 

Handbuch  der  Hautkrankheiten,  II.,  p.  300, 
2Hebra,  Diseases  of  the  Skin,  V.,  p.  25. 


Che  Sfcin 


221 


(a)  ECZEMA 


/^Pus/% 

l/f^l 

IvJe' 


(c)  ACNE 


(d)  HYPERHIDROSIS 


(e)  PRURITUS 


(f)  BLUSHING 


UMate  Xili.— Circles  associated  with 
the  Shin. 


222          tnctous  Circles  in  Disease 

a   disappearance    of   elastin   caused    by  a   chronic 
oedema. 

Unna  writes  : 

"  Owing  to  the  loss  of  elastin,  the  oedematous  skin 
gradually  loses  more  and  more  elasticity  ;  that  is,  the 
spontaneous  elastic  recoil  of  the  collagenous  tissue, 
displaced  by  pressure  or  by  movements  of  the  body, 
takes  place  more  and  more  slowly  and  incompletely  ; 
the  muscles  of  the  skin  lose  a  great  part  of  their  action 
on  the  skin  texture.  Thus  we  have  an  additional 
factor,  favouring  the  oedematous  swelling  of  the  cutis. 
By  the  oedema  directly  attacking  the  elastin  it  interferes 
with  the  most  important  factor  in  the  healing  of 
oedema  and  induces  an  incurable  circulus  vitiosus,  which 
terminates  in  complete  loss  of  resistance  of  the  skin, 
rupture  of  the  epidermis,  and  lymphorrhcea  externa."1 

Eczema  may  also  provoke  reverberations  in 
distant  regions  of  the  body  which  react  on  the 
primary  disorder.  Such  reverberations  are  not 
uncommonly  observed  in  elderly  persons  \vhose 
depressed  vitality  may  have  favoured  the  dermatitis, 
while  this  is  in  turn  aggravated  by  its  effects. 

Insomnia  due  to  persistent  irritation  is  not  an 
uncommon  intermediary.  In  other  cases  the  diges- 
tive system  appears  to  be  affected  by  the  cutaneous 
eruption  and  vice  versa. 

Malcolm  Morris  writes  : 

"  The  irritation  of  the  skin  may  .  .  .  set  up  reflex 
irritation  in  the  intestine,  preventing  the  proper 
digestion  of  food.  The  irregularity  of  the  bowels 
-reacts  in  turn  on  the  skin,  and  thus  a  Vicious  Circle  is 
established."2 


1  Histopathology  of  Diseases  of  the  Skin,  p.  40.     Cf.  also 

Koch,  Archiv  /.  Dcrmatologic  und  Syphilis,  XXXIV., 
p.  228. 

2  Diseases  of  the  Skin,  p.  276.     Cf.  also  Kaposi,  I.e.,  pp. 

918-922  (quoted  in  British  J.  of  Dermatology,  1901, 
XIII,  p.   37-) 


Sfcin  223 


Intertrigo.  Morbid  correlations  may  also  com- 
plicate intertrigo,  a  dermatitis  which  is  liable  to 
occur  when  opposing  surfaces  of  the  skin  remain 
long  in  contact  and  exposed  to  the  natural  heat 
and  moisture  of  the  body.  The  superficial  epithelium 
is  then  apt  to  desquamate,  leaving  the  deeper  layers 
of  the  skin  exposed  to  the  air.  From  these  denuded 
surfaces  free  exudations  take  place  which  tend 
to  undergo  decomposition  and  to  set  up  further 
irritation  and  further  exudation.  Cause  and  effect 
react  on  each  other. 

Examples  of  such  intertrigo  are  often  seen  in 
young  children  whose  ears  are  covered  and  pressed 
to  the  sides  of  the  head  by  a  tight  fitting  cap  or 
bonnet,  this  head-dress  amongst  the  poor  being 
often  worn  for  days  together.  The  posterior  aspect 
of  the  auricle  and  the  adjacent  integument  of  the 
head  are  then  often  attacked  by  intertrigo. 

Hyde  writes  : 

"  In  such  localities  the  disorder,  beginning  as  an 
erythema  traumaticum,  proceeds  by  its  irritative 
effects  to  stimulate  the  secretion  of  sweat,  which  is 
freely  poured  out  between  the  adjacent  folds  of  skin, 
and  may  there  temporarily  be  imprisoned.  The 
surface,  heated  and  reddened,  is  also  somewhat  macer- 
ated by  the  effused  perspiration,  and  the  latter,  when 
chemically  altered,  as  it  is  frequently  under  these 
circumstances,  adds  still  further  to  the  original  dis- 
order." l 

Urticaria.  Urticaria  is  another  form  of  der- 
matitis which  is  accompanied  by  severe  itching  and 
burning,  which  compel  the  patient  to  scratch 
furiously  in  order  to  obtain  relief.  The  scratching, 
whilst  affording  a  sense  of  satisfaction,  only  too 
often  provokes  a  fresh  crop  of  wheals. 


Diseases  of  the  Skin,  p.    143. 


224         IDicioug  Circles  in  Disease 

Gaucher  writes  : 

"  The  wheals  are  accompanied  by  intense  itching, 
which  causes  the  sufferer  to  scratch  himself.  This 
scratching  gives  rise  to  a  further  crop  of  wheals."1 

A  very  similar  process  occurs  in  lichen  ruber. z 

Clavus.  A  corn  is  primarily  a  protective  hyper- 
keratosis  caused  by  intermittent  pressure,  and  occurs 
in  situations  where  the  skin  is  most  liable  to  pressure, 
such  as  the  plantar  region.  In  the  centre  of  the 
thickened  horny  layer  a  conical  plug  or  core  usually 
forms  and  this  by  pressing  on  the  underlying  sensitive 
corium  sets  up  irritation  and  stimulates  the  papillae 
to  rapid  proliferation.  The  more  the  papillae  are 
irritated  the  more  rapidly  they  grow,  and  the  more 
they  grow  the  more  is  the  corn  raised  above  the 
surface  and  therefore  exposed  to  pressure. 

Ellis  writes  : 

"  The  relation  between  corns  and  too  tight  or  badly 
fitting  boots  is  too  obvious  for  dispute.  Corns  are 
illustrations  of  the  law  that  intermittent  pressure  and 
friction  cause  over-growth.  The  cuticle  becomes  thick- 
ened at  the  pressure  point  until,  in  turn,  it  becomes 
itself  a  cause  of  pressure  from  its  own  hardness  and 
large  size.  Here  removal  of  the  cause  is  speedily 
followed  by  disappearance  of  the  effect."3 

Callosities  are  also  due  to  hypertrophy  of  the 
horny  layer  and  are  often  complicated  by  inflam- 
mation of  the  underlying  corium,  cause  and  effect 
reacting  on  each  other.  A  similar  reciprocation 
is  present  in  the  case  of  bunions.4 


1  Maladies  de  la  Peau,  p.  60. 
2 Gaucher,  I.e.,  p.  133. 

3  The  Human  Foot,  p.  89. 

4  Ellis,  l.c.,  p.  86. 


Sfun  225 


II.     PARASITIC    DISORDERS 
(a)    Animal    Parasites 

Oxyurides.  A  familiar  illustration  of  reciprocal 
correlations  due  to  an  animal  parasite  is  met  with  in 
the  case  of  oxyurides.  The  irritation  at  the  anus 
and  the  consequent  scratching  lead  to  portions  of 
the  helminths  or  to  their  eggs  being  caught  under 
the  finger-nails,  conveyed  to  the  mouth  and  swal- 
lowed. From  the  stomach  the  ova  pass  into  the 
intestines  and  rapidly  attain  sexual  maturity.  In 
this  way  the  irritation  ensures,  by  auto-infection, 
successive  generations  of  the  parasite. 

Scabies.  Scabies  may  also  be  perpetuated  through 
the  itching  and  scratching  excited  by  the  acari. 
The  parasite  may  lodge  under  the  finger-nails,  and 
thus  be  transferred  from  one  part  of  the  body  to 
another. 

Pediculosis.  Similar  correlations  may  be  associ- 
ated with  pediculi  capitis.  The  crawling  and  suck- 
ing of  the  lice  cause  itching,  the  itching  provokes 
scratching  of  the  infected  area,  the  scratching 
transfers  the  lazy  louse  to  fresh  pastures.  Moreover 
the  finger-nails  often  produce  excoriations  and 
exudations,  and  thus  supply  further  food  material 
for  the  lice  and  accelerate  their  propagation.  The 
louse  itself  secures  its  own  nutriment,  for  when  it 
has  satisfied  its  appetite  and  withdrawn  its  haustel- 
lum,  a  drop  of  blood  wells  up  to  the  surface,  thus 
supplying  further  food. 

Again  the  inflammation  and  tenderness  of  the 
skin  associated  with  pediculosis  prevent  the  proper 
use  of  the  brush  and  comb.  The  diseased  spot  and 
its  infesting  colony  are  left  undisturbed  so  that 
the  lice  can  multiply  at  their  leisure.  Moreover  the 
cutaneous  exudations  readily  form  crusts  and  glue 


226         IDicious  Circles  in  S>ieea0e 


the  hairs  together,  thus  affording  a  hiding-place 
for  the  increase  of  the  parasites.  Especially  is  this 
the  case  in  those  countries  where  the  plica  polonica 
is  still  in  fashion  ;  no  wonder  that,  in  Hebra's 
words,  "  the  lice  swarm  as  if  one  had  disturbed  a 
nest  of  ants." 

Some  writers  believe  that  severe  deprivation  and 
exhaustion  such  as  occur  during  war  greatly  favour 
the  extension  of  lousiness,  while  this  condition 
tends  to  further  debility.  This  sequence  of  events 
was  often  observed  during  the  Crimean  war,  and 
was  doubtless  dependent  on  the  severe  hardships 
endured  by  the  troops. 

Longmore  writes  : 

"  The  lice  multiplied  with  marvellous  rapidity  in  the 
clothes  and  persons  of  men  who  became  ansemiated  and 
much  debilitated,  and  the  increase  of  vermin,  and 
increase  of  debility,  by  mutual  co-action,  went  on  at 
least  at  geometrical  ratio,  until  death  carried  off  the 
man."  l 

(b)    Vegetable    Parasites 
These  may  be  subdivided  into  : 
(i.)     Fungi 
(ii.)     Bacteria 

(i.)     Fungi 

Ringworm.  Some  important  reciprocations  are 
established  when  ringworm  invades  the  hairy  or  the 
glabrous  regions  of  the  skin.  For  example,  if  an 
endothrix  member  of  the  trichophytons  insinuates 
itself  between  the  cuticle  cells  of  the  hair,  it  rapidly 
proliferates,  so  that  the  shaft  becomes  stuffed  with 
spores,  grows  brittle  and  readily  splits  or  breaks 
off.  The  detached  portion  laden  with  spores  is  then 
free  to  spread  infection  far  and  wide  ;  in  fact  the 

1  British  Med.  /.,  1914,  IT.,  p.  679. 


Gbe  Sfctn  227 


continual  breaking  off  of  the  hair  is  the  chief  means 
by  which  the  spores  of  the  parasite  are  dispersed. 
The  fragment  of  hair  remaining  in  the  follicle  may 
also  perpetuate  the  infection. 

Another  complication  occurs  when  ringworm  pro- 
vokes itching  and  scratching,  and  so  leads  to  the 
auto-inoculation  of  fresh  foci.  The  parasite  is  apt 
to  lodge  under  the  nails  and  to  be  transferred  to 
another  portion  of  the  scalp  ;  or  the  nail  itself 
may  be  invaded  by  onychomycosis,  which  facilitates 
the  inoculation  of  fresh  areas.  The  ordinary  comb- 
ing and  cleansing  of  the  hair  also  assists  in  diffusing 
infection,  and  this  leads  to  further  cleansing.  Es- 
pecially injurious  is  the  washing  of  the  hair,  since 
water  nourishes  the  fungus. 

Sabouraud  writes  : 

"  Any  attempt  to  cleanse  the  diseased  scalp  dis- 
perses the  infective  agent  and  creates  fresh  points  of 
inoculation.  In  girls,  for  instance,  the  linear  tracts 
left  by  the  use  of  the  comb  are  indicated  by  rows  of 
diseased  hairs."  1 

When  the  fungus  infects  the  non-hairy  skin,  it 
causes  dissociation  of  the  epidermic  cells,  and  the 
debris  supplies  the  parasite  with  the  sustenance 
necessary  for  its  further  growth.  The  irritation 
also  provokes  inflammation  and  exudation,  both  of 
which  are  favourable  to  rapid  multiplication. 

Similar  correlations  are  established  in  the  case  of 
favus  and  tinea  versicolor.  The  fungus  may  provoke 
inflammatory  reactions,  as  shown  by  discomfort, 
burning  or  itching.  The  consequent  rubbing  or 
scratching  may  then  transfer  the  fungus  to  fresh 
areas,  where  the  infection  is  reproduced. 

In  some  regions  of  the  body  fungus  infection  is 
especially  prone  to  provoke  hypersecretion  which 
supplies  further  nutriment  and  thus  favours  parasitic 


Pratique  Dermatologique,  IV.,  p.   480. 


228         IDictoug  Circles  in  Bieeaee 

growth  and  extension.  A  good  example  of  this  is 
presented  by  otomycosis  due  to  some  form  of 
aspergillus  or  other  fungus.  Both  the  ceruminous 
and  sebaceous  glands  of  the  external  auditory 
meatus  may  be  stimulated  by  activity  of  the 
parasite  which  penetrates  into  the  lining  membrane. 
Even  obstruction  of  the  meatus  with  retention  of 
secretions  is  occasionally  brought  about. 

(ii.)    Bacteria 

Impetigo.  Impetigo  contagiosa  may  be  taken 
as  an  example  of  a  dermatitis  due  to  bacterial 
infection.  The  eruption  gives  rise  to  discomfort 
and  itching  ;  the  itching  leads  to  scratching. 
The  finger-nails  become  infected  by  the  sero-pus 
containing  the  streptococci,  which  then  are  readily 
inoculated  into  any  excoriations  produced  by  the 
scratching  (platC  XIII.  b).  Indeed  repeated  auto- 
inoculations  may  cause  an  indefinite  persistence  of 
the  disease. 

Sequeira   writes  : 

"  The  eruption  itches,  and  auto-inoculation  is 
exceedingly  common.  By  scratching  and  simple  con- 
tact fresh  spots  form  with  great  rapidity,  and  large 
areas  may  be  involved." * 

Ecthyma,  furunculosis  and  sycosis  may  be  per- 
petuated by  a  similar  mechanism. 

III.     DISORDERS     ASSOCIATED     WITH 

APPENDAGES   OF  THE   SKIN— HAIR,  NAII^S, 

SEBACEOUS  AND  SWEAT  GLANDS. 

(a)    The    Hair 

Several  circular  reactions  associated  with  the 
hair  (e.g.  pediculosis,  ringworm  etc.)  have  been 
already  alluded  to.  There  remain  others  which 
must  now  be  dealt  with. 

1  Diseases  of  the  Skin,  p.   149. 


SFun  229 


Baldness.  According  to  some  writers  baldness 
may  be  dependent  on  reciprocally  acting  factors. 
Owing  to  the  fashion  of  keeping  the  head  covered 
and  of  thus  depriving  the  hair  of  sun,  air  and 
nourishment  (especially  if  a  hard-rimmed,  tight  hat  is 
worn)  the  hair  in  the  regions  most  frequently  covered 
tends  to  atrophy  and  fall  out.  The  result  is  more 
or  less  extensive  baldness,  which  in  its  turn  necess- 
itates increased  use  of  the  head  gear. 
Brocq  writes  : 

"  Persons  who  keep  their  heads  constantly  covered 
with  a  heavy  and  tightly  fitting  hat  lose  their  hair 
much  more  rapidly  than  those  who  keep  their  head 
uncovered."1 

Hirsuties.  The  opposite  condition,  viz.  hirsuties, 
is  often  associated  with  an  artefact  owing  to  the 
practice  of  epilation  or  to  the  application  of  depila- 
tories. Neither  of  these  methods  of  getting  rid  of 
hair  possesses  any  permanent  value  ;  they  merely 
make  new  hair  grow  more  luxuriantly  than  before  by 
increasing  the  local  circulation  and  provoking  hyper- 
trophy of  the  papillse.  The  hypertrichosis  leads 
to  epilation  and  this  to  further  hypertrichosis. 
It  must,  however,  be  added  that  the  causation 
both  of  baldness  and  hirsuties  is  still  sub  judice. 
The  sequence  of  events  suggested  above  is  by  no 
means  universally  accepted  ;  doubtless  the  aetio- 
logical  factors  vary  in  different  cases. 

(b)    The   Nails 

The  nails  have  more  than  once  been  mentioned 
as  agents  in  the  perpetuation  of  disease.  At  times 
they  aggravate  the  pruriginous  disorders  they  are 
intended  to  relieve,  as  in  the  case  of  eczema  and 
urticaria.  At  other  times,  when  used  to  relieve 
pruritus,  they  become  the  carriers  of  infection,  as 
in  the  case  of  oxyurides  or  impetigo. 

1  Pratique    Dermatologique,  I.,  pp.  318,  375. 


230          IDicious  Circles  in  Disease 


Onychogryphosis.  The  nails  themselves  are 
sometimes  diseased.  Thus  Heller  has  drawn  atten- 
tion to  a  process  of  reciprocation  that  is  established 
in  onychogryphosis,  owing  to  a  keratoma  in  the 
nail  bed  : 

"  This  cushion-like  growth,  caused  by  the  inflam- 
matory irritation  in  the  matrix,  raises  up  the  nail- 
plate  and  disturbs  its  natural  growth.  This  raising 
of  the  nail  also  increases  the  angle  between  the  matrix 
and  the  nail-plate,  as  this  latter  emerges  from  the 
posterior  fold.  A  circulus  vitiosus  is  now  established, 
since  the  space  between  the  plate  and  the  matrix 
(owing  to  the  plate  being  obliquely  raised)  again 
becomes  filled  by  the  horny  growth."  1 

Ingrowing  Toe-Nail.  A  somewhat  similar  pro- 
cess may  complicate  onychia,  where  inflammation 
leads  to  accelerated  growth,  and  this  in  turn  intensi- 
fies the  inflammation.  This  condition  occurs  with 
ingrowing  toe-nail,  as  Sir  Jonathan  Hutchinson 
points  out  : 

"  As  soon  as  any  degree  of  inflammation  has  been 
set  up,  the  conditions  aggravate  each  other  ;  the 
inflamed  nail  expands  and  grows  laterally  against  the 
raw  surface,  now  unable  to  tolerate  any  pressure. 
No  doubt,  also,  as  in  onychia  maligna,  the  secretion 
produced  is  in  itself  a  source  of  irritation."  - 

(c)    The    Sebaceous    Glands 

Sebaceous  Cysts.  Various  skin  disorders  are 
due  to  obstruction  of  efferent  ducts  and  the  con- 
sequent accumulation  of  retained  secretions.  For 
example,  hyperkeratosis  of  the  outer  third  or  funnel 
of  a  pilo-sebaceous  follicle  may  give  rise  to  a  comedo 
plug,  whose  presence  acts  as  an  irritant  and  pro- 
motes further  hyperkeratosis.  Sebaceous  cysts  often 

aMracek,  Handbuch  der  Hautkrankheiten,  IV.  (ii.),  p.  569. 
-Lectures  on  Clinical  Surgery,  I.   (i.),  p.  144. 


Sfcin  231 


arise  by  a  similar  process,  the  accumulation  of 
sebaceous  matter  causing  hyperactivity  of  the 
follicular  walls  and  increased  accumulation.  The 
same  may  be  said  of  acne  vulgaris,  where  in- 
flammation of  the  walls  of  the  follicles  is  probably 
associated  with  microbic  infection.  The  increased 
secretion  leads  to  increased  irritation  and  vice 
versa. 

lyarge  accumulations  of  fat  and  epidermis,  due  to 
seborrhcea,  are  sometimes  observed  in  the  umbilical 
fossa.  In  course  of  time  this  mass  may  become 
rancid  and  irritating,  thus  provoking  increased 
secretion  and  accumulation.  Seborrhcea  genitalium 
is  another  example,  which  arises  when,  through 
want  of  cleanliness,  smegma  is  allowed  to  collect 
and  decompose. 

Acne  Rosacea.  Some  reciprocal  correlations  may 
be  displayed  in  acne  rosacea  and  account  for  its 
chronicity.  The  disease  often  begins  with  tem- 
porary but  recurrent  angio-neurotic  flushing  of 
the  skin  over  the  central  portion  of  the  face.  In 
course  of  time  these  flushes  give  rise  to  a  network 
of  vascular  dilatations  associated  with  telangiectases 
and  acne-like  papules,  resulting  eventually  in  inflam- 
mation of  the  sebaceous  glands.  The  telangiectases 
and  the  pustules  appear  to  favour  one  another. 
Brocq  writes  : 

"  A  form  of  Vicious  Circle  is  established.  The 
inflamed  acne  favours  the  afflux  of  blood  to  the  face, 
and  aggravates  the  dilatation  of  the  blood-vessels  ; 
while,  on  the  other  hand,  the  chronic  congestion  of 
the  skin  favours  the  production  of  acne  and  the  indura- 
ation  round  the  base  of  the  pustules."  1 

The  latter  stage  of  the  disease  is  characterized  by 
an  enormous  development  of  sebaceous  glands  and 


1  Dermatologie    Pratique,    I.,    p.    831.     Cf.    also    Pratique 
Dermatologique,   I.,   p.    227. 


232          IDicious  Circles  in  H)i0ea0e 


fibrous  tissue — changes  which  reciprocally  aggravate 
one  another  (]MatC  XIII.  c).     The  process  is  similar 
to  that  met  with  in  rhinophyma  and  acne  cheloid. 
Wilfred  Fox  writes  : 

"  The  fibrous  tissue  obstructs  further  the  sebaceous 
ducts,  renders  the  outflow  more  difficult,  and  by 
stagnation  favours  additional  pustulation,  which  in 
its  turn  produces  fresh  fibrous  tissue,  and  so  a  Vicious 
Circle  is  set  up." l 

(d)    The    Sweat    Glands 

Hyperhidrosis.  General  hyperhidrosis  is  met 
with  in  both  acute  and  chronic  diseases  ;  in  both 
cases  it  may  perpetuate  its  own  cause.  Almost 
every  severe  disease  that  is  accompanied  by  great 
prostration  may  be  complicated  by  excessive  sweats, 
which,  on  the  one  hand,  result  from  the  state  of 
exhaustion,  and,  on  the  other,  aggravate  such  ex- 
haustion. 

Bouveret  writes  : 

"  The  colliquative  sweats  of  convalescence  are  no- 
thing more  than  the  expression  of  a  state  of  profound 

weakness The  convalescent  perspires  because 

he  is  weak,  and  this  perspiration  aggravates  his  weak- 
ness. This  is  a  Vicious  Circle  from  which  he  must 
escape  without  delay."2 

Perhaps  the  most  violent  attacks  of  hyperhidrosis 
are  seen  in  tuberculosis,  where  they  may  cause 
complete  soaking  of  the  linen.  The  excessive  sweats 
weaken  the  patient  to  an  extraordinary  degree  and 
are  said  often  to  hasten  the  end.3 

The  same  process  in  a  less  severe  form  is  seen  in 
neurasthenia,  rheumatism  and  obesity.  Neuro- 
pathic individuals  not  uncommonly  are  troubled 

JAllbutt  and  Rolleston,  System  of  Medicine,  IX.,  p.  697. 

2I,es  Sueurs  Morbides,  p.  121. 

3  New  York  Medical  /.,  1918,  II.,  p.  475. 


Skin  233 


by    night    sweats    which    perpetuate    the    nervous 
debility.1 

In  rheumatic  persons,  on  the  other  hand,  it  is 
especially  the  skin  over  the  affected  muscles  that 
sweats,  but  this  is  very  apt  to  lead  to  chill  and 
increased  rheumatism. 

Llewellyn  and  Jones  write  : 

"  A  local  hyperidrosis  of  the  loins,  by  leading  to 
soaking  of  the  adjacent  underclothing  and  conse- 
quently to  local  cooling,  almost  infallibly  induces  an 
exacerbation  and  thus  a  Vicious  Circle  ensues."2. 

Some  stout  persons  whose  adipose  tissues  dimin- 
ish the  amount  of  heat  given  off  by  radiation  and 
conduction,  are  much  troubled  by  abundant  perspir- 
ations. These  make  the  sufferer  lazy,  and  thus 
tend  to  increased  obesity  and  perspiration  (JMatC 
XIII.  d). 

Hyperhidrosis  of  the  axillary  regions  frequently 
causes  women  to  wear  impervious  shields  in  order 
to  protect  their  dress  from  unsightly  stains.  These 
shields,  however,  encourage  retention  and  decom- 
position of  the  secretions,  and  thus  favour  irritation 
of  the  skin  and  further  hyperhidrosis. 

Anhidrosis.  In  persons  who  take  too  little 
exercise  an  inadequate  amount  of  perspiration  may 
also  establish  morbid  correlations.  The  want  of 
exercise  causes  anhidrosis,  insufficient  consumption 
of  liquid,  constipation,  lassitude  and  a  further 
disinclination  for  exercise. 

Dyshidrosis.  Some  dermatologists  have  attri- 
buted pompholyx  or  dyshidrosis  to  disorder  of  the 
sudoriparous  apparatus,  although  the  matter  is  still 
under  discussion.  There  can,  however,  be  no  doubt 
that  the  associated  itching  and  scratching  are  both 
cause  and  effect  of  the  disorder. 

1  Miiller,  Handbuch  der  Neurasthenic,  p.  166. 
2Fibrositis,  p.   174. 


234         Dicious  Circles  in  disease 


Brocq  writes  : 

"  The    patient    complains    of    intense    itching    and 
burning.     The   more  he   scratches   himself   the   more 
numerous    and    the  larger   do   the   vesicles   become. 
They  seem  almost  to  develop  under  the  fingers  at  the 
itching  spots  as  these  are  being  rubbed."1 
Retention  cysts  of  the  sweat  glands  may  be  due 
to  the  same  mechanism  as  produces  retention  cysts 
elsewhere.     Owing  to  the  narrow  lumen  the  sweat 
duct   is   readily   obstructed   or   kinked,   leading  to 
accumulation  of  sweat  and  cystic  dilatation.     This 
may  in  turn  cause  further  obstruction  and  accumu- 
lation,  until  the  cyst  reaches  a  considerable  size. 

IV.     NEUROSES 

All  dermatoses  are  liable  to  be  complicated  by  a 
neurotic  element.  But  it  will  be  convenient  to 
group  under  a  separate  heading  some  conditions 
where  the  neuroses  are  predominant. 

Pruritus.  A  familiar  example  is  presented  by 
pruritus,  a  disorder  which  may  be  independent  of 
local  irritation  or  of  pathological  changes  in  the  skin. 
In  some  neuropaths  who  have  suffered  from  pruritus 
the  mere  fear  of  an  attack  may  suffice  to  bring  it  on. 
The  liability  is  greatest  in  such  a  place  as  a  church 
or  a  theatre,  where  there  is  no  opportunity  of  grati- 
fying the  desire  to  scratch.  The  itching  gradually 
increases  in  intensity,  and  when  scratching  can  be 
indulged  in  the  pruritus  is  further  aggravated  owing 
to  increased  reflex  irritation.  The  phobia  thus 
nourishes  itself  (plate  XIII.  e). 

After  a  period  of  pleasurable  excitement  a  form 
of  orgasm  takes  place  accompanied  by  a  discharge 
of  nervous  energy  and  a  relief  of  the  pruritus. 

In  cases  of  persistent  pruritus  there  may  be  estab- 
lished what  Unna  calls  the  "  circulus  vitiosus  of 

1  Dermatologie  Pratique,  II.,  p.   133. 


Gbe  Sfcin  235 


scratching  and  hyperkeratosis,"1  a  correlation  which 
has  been  strongly  upheld  by  Brocq  and  Jacquet, 
although  other  dermatologists  believe  that  a  slight 
eczema  or  other  lesion  may  start  the  process.  If 
the  scratching  has  been  indulged  in  for  long,  a 
permanent  change  known  as  lichenification  is  apt 
to  follow.  This  again  perpetuates  the  pruritus,  as 
Macleod  has  described  : 

"  When  lichenification  is  established,  a  Vicious  Circle 
is  set  up,  for  the  thickening  of  the  skin  irritates  the 
nerve-endings  and  so  keeps  up  the  pruritus,  whilst 
the  rubbing  which  is  indulged  in  to  relieve  the  pruritus 
increases  the  lichenification."2 

In  other  cases  of  long-continued  pruritus  inner- 
vation  may  be  so  disturbed  as  to  produce  an  exagger- 
ated activity  of  the  reflex  mechanism  of  scratching. 
The  habit  may  persist  after  all  peripheral  lesion  has 
disappeared .  The  condition  resembles  that  occasion- 
ally met  with  in  other  muscular  mechanisms  such  as 
blepharospasm,  cough  or  vomiting. 

Pruritus  ani  and  pruritus  vulvae  have  been  dealt 
with  in  Chapters  VI.  and  VIII. 

Prurigo.  In  prurigo  also  the  neurotic  element 
plays  an  important  part.  There  has  been  much 
dispute  as  to  whether  the  scratching  gives  rise  to 
the  papules  or  the  papules  to  the  scratching  ;  but 
whatever  the  primary  cause  the  two  conditions  act 
and  react  on  each  other.  Thus  Sir  Jonathan 
Hutchinson  writes  : 

"  Prurigo,  from  whatever  cause  it  may  have  begun, 
tends  to  perpetuate  or  even  to  aggravate  itself.  It 
causes  itching,  and  the  itching  causes  scratching,  and 
the  scratching  extends  the  prurigo,  and  thus  the 
patient  goes  on  from  bad  to  worse."3 

Blushing.  Another  nervous  disorder  is  associ- 
ated with  blushing — a  vaso-motor  condition  pro- 

^Iracek,  Handbuch  der  Hautkrankheiten,  II.,  p.  306. 
~  Allbutt  and  Rolleston,  System  of  Medicine,  IX.,  p.  298. 
3 Lectures  on  Clinical  Surgery,  I.  (i.),  p.  30. 


236          IDtcious  Circles  in  Disease 

voked  by  emotional  disturbance  and  showing  itself 
by  dilatation  of  the  blood-vessels  of  the  skin.  It  is 
especially  common  in  nervous,  self-conscious  women. 
The  more  self-conscious,  the  more  they  blush.  The 
harder  they  try  to  avoid  blushing  the  worse  they 
suffer  (plate  XIII.  f). 

Roussy  and  lyhermitte  write  : 

"  Blushing  and  trembling  are  as  a  matter  of  fact 
simply  reflex  manifestations  of  an  emotional  temper- 
ament.    Just  as  the  blushing  of  an  ereutophobe  in- 
creases with  the  progress  of  his  phobia,  so  the  trembling 
of  the  tremophobe  increases  with  his  dread  of  tremb- 
ling.    The  physical  phenomenon  creates  the  obsession 
which  in  its  turn  aggravates  the  physical  reaction  ; 
the  aggravation  of  this  latter  similarly  reacts  on  the 
mental  trouble.     Thus  is  established  a  Vicious  Circle 
of   reciprocal   psychophysical  reactions,  of  which   the 
result  is  a  real  state  of  obsession."1 
In  some  sensitive  females  ereutophobia  has  been 
a  real  martyrdom  and  destroyed  all  the  happiness 
of  life.     Girls   have  had   to   abandon   school   life  ; 
women  have  even  contemplated  suicide  to  escape 
their  obsession.    Facial  seborrhcea  in  neurotic  women 
may  also  be  a  self-perpetuating  condition  through 
a  similar  mechanism.2 

In  certain  predisposed  persons  great  mental 
anxiety  or  depression  may  provoke  cutaneous 
eruptions,  thus  shewing  how  intimately  the  skin 
and  nervous  system  are  connected.  The  eruption 
naturally  aggravates  the  neurosis. 
Fernet  writes  : 

"  Continual  mental  stress  and  want  of  sleep  may  lead 
to  a  form  of  eruption  on  the  skin  which  when  wide- 
spread is  in  itself  so  irritating  as  to  lead  to  further 
depression  of  the  sufferer,  in  a  word  to  what  is  called 
a  Vicious  Circle."3 

^es  Psychonevroses  de  Guerre,  p.  65. 
2Kaposi,  Diseases  of  the  Skin,  p.  123. 
3  The  Health  of  the  Skin,  p.  19. 


Chapter  jfifteen 


VETERINARY    DISEASES 

ANY  of  the  Vicious  Circles  occurring  in 
the  domestic  animals  are  similar  to  those 
occurring  in  man,  as  indeed  might 
be  expected  from  their  morphological 
and  physiological  affinities. 
On  the  other  hand  domestic  animals  afford 
examples  that  are  little  known  in  human  pathology, 
owing  to  peculiarities  in  structure  and  function. 
Amongst  them  are  various  forms  of  impaction  of 
food  in  such  regions  of  the  alimentary  tract  as  the 
peculiarly  shaped  stomach  of  the  horse,  the  rumen 
of  cattle  or  the  crop  of  the  bird.  Again  hairy, 
woolly  or  feathery  coats  favour  parasitic  disease 
to  an  extent  that  man  happily  escapes. 

Attention  may  be  drawn  to  a  few  examples  which 
occur  in  the  more  important  domestic  animals,  and 
which  may  serve  to  illustrate  the  morbid  process. 
We  may  deal  in  order  with  the  nervous,  the  cardio- 
vascular, the  respiratory,  the  digestive  and  other 
systems.1 

I.  THE  NERVOUS  SYSTEM 
Apoplexy.  Cerebral  haemorrhage  is  less  common 
in  the  domestic  animals  than  in  man  since  they 
are  less  subject  to  degenerative  changes  in  the 
arteries.  Nevertheless  horses,  cattle,  dogs,  birds 
and  other  animals  suffer  occasionally,  and  the 
haemorrhage  may  perpetuate  itself  by  the  following 
mechanism : 

lCf.   also  Veterinary   Diseases  and  the  Vicious  Circle,  by 
J.B.H.,  The  Veterinary  News,  1918,  I.,  pp.  218,  226. 

237 


238         IDicious  Circles  in  SHeeaee 

Under  normal  conditions  the  blood-pressure  in. 
the  cerebral  arteries  is  considerably  higher  than  the 
intra-cranial  pressure,  being  in  horses  equal  to  ca. 
200-300  mm.  Hg  and  in  dogs  to  ca.  100-150  mm. 
Hg,  while  the  intra-cranial  pressure  is  practically 
nil.  Cerebral  haemorrhage,  however,  raises  the  intra- 
cranial  pressure  nearly  up  to  arterial  pressure,  and 
in  so  doing  renders  the  vaso-motor  centres  anaemic. 
In  their  urgent  need  for  blood  these  centres  respond 
by  a  great  splanchnic  vaso-motor  constriction, 
which  may  raise  the  pressure  far  above  the  normal 
level.  Unhappily  the  rise  is  apt  to  prove  disastrous 
by  starting  the  haemorrhage  afresh.  A  further 
increase  of  intra-cranial  pressure  then  results,  and 
the  whole  sequence  is  repeated. 

The  increased  blood-pressure  frequently  causes 
death  by  paralysis  of  the  respiratory  centre  in  the 
medulla. 

Hydrocephalus.  Chronic  hydrocephalus  is  often 
complicated  by  the  presence  of  a  Vicious  Circle 
which  may  lead  to  the  destruction  of  the  brain. 

In  health  the  cerebro-spinal  fluid  is  continually 
being  secreted  by  the  choroid  plexus  into  the 
ventricles,  whence  it  escapes  into  the  subarachnoid 
space,  secretion  and  absorption  being  adjusted  by  a 
self -regulating  mechanism.  Various  morbid  pro- 
cesses, however,  may  narrow  the  communicating 
passages,  causing  an  accumulation  of  fluid  in  the 
ventricles,  which  may  so  displace  the  adjacent 
parts  as  to  increase  the  stenosis  to  which  the  dilat- 
ation was  primarily  due.  For  example,  the  tentorium 
cerebelli  may  be  pushed  down  on  the  corpora 
quadrigemina  and  these  in  turn  may  press  on  the 
Sylvian  duct,  thus  tending  to  diminish  its  lumen  ; 
the  obstruction  in  turn  increases  the  ventricular 
accumulation  and  so  on.  Such  accumulation  may 
lead  to  disastrous  consequences.  The  pressure  of 


IDeterinan?  Diseases 


239 


X)S 


FO/V^ 

•"% 


(a)  CARDIAC  FAILURE 


I 

ll 

^ 


(b)  STRONQYLUS  INFECTION 
OF  LUNG 


Gr*.  ^  /"  ^s%^ 

^  ^f/       \  \ 

J  i(      )! 
_.£ 


(c)  IMPACTION  OF  STOMACH          (d)  URETHRAL  CALCULUS 


f 


ifc/,,- 

Scf»/& 

L%* 


y 


(c)  EGG-BINDING 


(I)  SCABIES 


xiv.— Circles  associated  with 
IDeterinarg  Diseases, 


240          Dlcious  Circles  in  Disease 

fluid  in  the  ventricles  stretches  their  walls  which 
grow  thin  and  weak.  The  more  they  stretch  the 
thinner  they  grow  and  vice  versa.  The  associated 
changes  in  the  brain  may  be  very  striking.  In  the 
worst  cases  the  cerebral  tissues  may  be  so  com- 
pressed and  stretched  as  to  be  reduced  to  a  thin 
membrane,  all  trace  of  convolutions  being  lost,  and 
the  basal  ganglia  scarcely  recognisable. 

The  changes  caused  by  hydrocephalus  are  most 
readily  effected  in  newly  born  animals,  whose  skull 
and  membranes  are  yielding  and  the  sutures  un- 
ossified. 

II.     THE      CARDIO- VASCULAR      SYSTEM 

Cardiac  Disease.  Domestic  animals  frequently 
suffer  from  heart  disease  and  such  disease  is  com- 
plicated by  a  variety  t>f  circular  reactions  (||MHte 
XIV.  a).  Striking  examples  are  met  with  in  horses 
which,  whether  used  for  draught  or  for  racing 
purposes,  are  liable  to  excessive  demands  on  the 
heart,  which  not  uncommonly  breaks  down  under 
the  strain.  The  resulting  disease,  whether  myocar- 
diac  or  valvular,  calls  forth  compensatory  changes 
which  tend  to  make  good  the  insufficiency  and  may 
continue  operative  for  a  number  of  years. 

Sooner  or  later,  however,  such  compensation 
usually  fails,  and  the  heart  becomes  unequal  to  its 
work.  The  other  organs  that  depend  on  the  heart 
for  their  activity,  such  as  the  lungs,  intestines,  liver, 
kidneys  etc.  are  then  thrown  into  disorder.  The 
processes  of  oxygenation,  nutrition  and  elimination 
are  impaired,  while  this  impairment  of  vital  func- 
tions reacts  injuriously  on  the  damaged  heart, 
increasing  its  disability  and  aggravating  its  weak- 
ness. 

Such  a  Vicious  Circle  may  end  in  chronic  invali- 
dism  or  in  death. 


IDeterinan?  Dieeaeee  241 

Worm  Aneurysm.  Another  common  disorder 
in  horses  is  the  so-called  worm  aneurysm  due  to 
the  presence  in  the  anterior  mesenteric  or  other 
arteries  of  the  larvae  of  the  haematozoon  strongylus 
vulgaris  (sclerostomum  vulgare).  These  larvae  set 
up  endo-arteritis,  as  a  result  of  which  the  arterial 
walls  grow  weak,  yield  to  the  blood-pressure  and 
form  an  aneurysm.1  The  more  they  yield  the 
larger  the  aneurysm  ;  the  larger  the  aneurysm  the 
greater  the  tension  on  the  walls,  since  vascular  tension 
increases  with  calibre.  Thus  the  dilatation  is  pro- 
gressive and  the  aneurysm  may  eventually  rupture 
with  fatal  results. 

The  aneurysm  and  associated  thrombosis  may 
also  cause  serious  circulatory  failure  in  the  intestines, 
followed  by  loss  of  peristalsis,  stasis,  fermentation 
and  dilatation.  These  conditions  aid  and  abet  one 
another,  so  that  further  reciprocations  are  initiated. 

III.     THE    RESPIRATORY    SYSTEM 

Chronic  Catarrh  of  the  Guttural  Pouches.  An 

interesting  Vicious  Circle  may  be  associated  with 
chronic  catarrh  of,  and  retention  of  secretions  in,  the 
guttural  pouches  of  the  horse.  The  mucous  mem- 
brane lining  the  pouches  may  from  various  causes 
become  congested  or  inflamed,  resulting  in  retention 
and  decomposition  of  the  secretions.  Such  decom- 
position leads  to  narrowing  of  the  openings  into  the 
pouches  and  further  obstruction  to  drainage.  Thus 
the  greater  the  obstruction  the  greater  the  irritation 
and  vice  versa.  In  course  of  time  the  retained 
secretions  may  form  cartilaginous  concretions  or 
chondroids  which  set  up  further  irritation.  Con- 
cretions weighing  as  much  as  2  Ibs.  have  been 
recorded.2 

1  Neumann,  Parasites  and  Parasitic  Diseases  of  Domesticated 

Animals,  p.  622. 
2M611er,  Operative  Veterinary  Surgery,  p.  92. 


242         Dicioue  Circles  In  Disease 

Tuberculosis.  Tuberculosis  is  a  wide-spread 
disease  affecting  many  of  the  domestic  animals  and 
involving  various  organs  in  the  animals  attacked. 
The  difficulty  of  eradication  is  largely  due  to  the 
various  Vicious  Circles  that  are  formed.  Space 
will  only  permit  of  a  few  references  to  the  disease 
as  met  with  in  cattle. 

Bovine  tuberculosis  propagates  itself  in  a  variety 
of  ways.  For  example,  tubercle-laden  sputa,  when 
loosened  by  cough,  may  be  aspirated  into  healthy 
parts  of  the  lung,  and  thus  start  fresh  foci.  Or  the 
sputa  may  be  swallowed  and  infect  the  alimentary 
tract,  whence  the  bacilli  pass  through  the  lymphatics 
and  return  to  the  lungs  where  the  disease  starts 
again,  and  where  fresh  materials  are  generated  for 
expectoration. 

The  astonishing  rapidity  with  which  pulmonary 
cavities  sometimes  form  and  enlarge  is  also  due  to 
the  operation  of  Circles.  In  some  cases  an  entire 
lung  may  be  destroyed,  so  that  the  bronchi  open 
into  a  vast  cavity  bounded  by  little  more  than  the 
pleura.  The  process  may  be  the  result  of  various 
causes.  Thus  a  mass  of  caseous  tubercles  may  be 
discharged  into  a  bronchial  tube,  leaving  a  cavity 
of  which  the  walls  are  in  active  tuberculous  evolu- 
tion. The  larger  the  surface  exposed  to  infection,  the 
more  rapidly  does  disintegration  take  place.  Thus  the 
cavity  tends  to  grow  eccentrically.  Again  the 
accumulation  of  the  stagnant  secretions  greatly 
favours  the  multiplication  both  of  the  tubercle 
bacilli  and  of  other  pyogenic  micro-organisms. 
These  mixed  infections  accelerate  the  advance  of 
the  tuberculosis  and  tend  to  the  further  enlargement 
of  the  cavities. 

With  these  and  other  Vicious  Circles  at  work  it 
is  no  wonder  that  tuberculosis  is  so  destructive 
a  disease.  Moreover  the  tuberculous  animal  may 
disseminate  infective  sputa  far  and  wide.  All  the 


lDetertnan>  H)i9ea0c0  243 


residents  in  a  cow-shed   may  be  infected  by  the 
introduction  of  one  diseased   animal. 

Emphysema.  The  expression  "  broken  wind  " 
is  loosely  applied  to  several  disorders,  but  is  best 
restricted  to  a  chronic  emphysema  of  the  pulmonary 
alveoli  which  is  a  steadily  progressive  condition  due 
to  the  operation  of  Vicious  Circles.  The  disease, 
frequently  met  with  in  the  horse,  may  result  from 
various  causes,  chronic  bronchitis  being  perhaps 
the  commonest.  The  bronchitis  is  often  accom- 
panied by  severe  coughing  and  by  very  tenacious 
expectoration  which  is  expelled  with  difficulty. 
The  cough  leads  to  increased  intra-pulmonary 
pressure  as  a  result  of  which  the  alveoli  yield  and 
dilate.  Their  walls  lose  their  natural  elasticity  and 
frequently  a  number  of  alveoli  become  confluent. 
The  secretions  tend  to  stagnate  in  the  dilated 
alveoli  and  thus  perpetuate  the  cough  which  in  its 
turn  promotes  further  alveolar  dilatation.  Thus 
the  process  is  self-aggravating  and  as  a  rule  is 
uncurable. 

In  order  to  overcome  the  loss  of  elasticity  in  the 
alveoli  a  greater  expiratory  effort  is  required  ; 
indeed  a  double  .expiratory  movement  frequently 
takes  place  while  inspiration  is  shorter  than  usual. 
A  chronic  dyspnoea  is  also  often  present,  dependent 
on  the  pulmonary  changes. 

In  course  of  time  the  circulation  through  the 
emphysematous  lungs  is  impeded,  as  a  result  of 
which  the  right  side  of  the  heart  undergoes  hyper- 
trophy, followed  by  a  subsequent  dilatation  which 
increases  both  the  bronchial  congestion  and  irritation. 

While  the  horse  is  at  rest  or  doing  light  work 
respiration  may  be  comparatively  easy.  But  labori- 
ous work  requiring  a  more  abundant  supply  of 
oxygen  severely  taxes  the  emphysematous  lungs. 
All  the  signs  of  respiratory  distress  show  themselves. 


244         IDieious  Circles  in  Disease 

In  order  to  assist  respiration  the  diaphragm  acts 
more  vigorously  than  usual,  and  as  a  result  the 
abdomen  frequently  assumes  a  pot-bellied  appear- 
ance. 

Lung- Worm  Disease.  This  disease,  sometimes 
called  verminous  bronchitis,  and  caused  by  several 
species  of  strongylus,  attacks  domestic  animals 
such  as  pigs,  cattle,  sheep  and  goats  (JMatC 
XIV.  b).  In  pigs  the .  strongylus  paradoxus  is  the 
special  parasite  which  inhabits  the  bronchial  tubes 
and  lungs,  where  it  provokes  congestion  and  the 
formation  of  large  cavities  known  as  worm-nodules.1 

Both  the  trachea  and  bronchi  may  be  dilated 
into  sacciform  pouches  in  which  the  worms  lie 
coiled,  surrounded  by  mucus,  pus  and  other  secretions 
from  which  they  derive  nourishment.  The  more 
numerous  the  parasites  the  greater  the  injury  caused 
and  vice  versa.  The  affected  animal  may  perish 
from  asphyxia  due  to  an  accumulation  of  the  worms. 

Syngamosis.  A  common  parasitic  respiratory 
disease,  popularly  known  as  "  gapes,"  is  due  to  a 
nematode  called  the  syngamus  trachealis  or  wind- 
pipe worm  which  inhabits  the  upper  part  of  the 
trachea  and  gives  rise  to  tracheo-bronchitis  in 
fowls  and  other  birds.2  The  worms  attach  them- 
selves by  suction  discs  to  the  mucous  membrane 
from  which  they  suck  blood.  The  larger  the  worms 
the  more  blood  do  they  inbibe  and  vice  versa. 
Adult  fowls  with  a  full-sized  trachea  are  not  much 
troubled  ;  but  in  younger  birds  the  entire  trachea 
may  be  blocked,  death  taking  place  from  asphyxia. 

1  Friedberger    and    Frohner,    Veterinary    Pathology,    II., 

p.  700. 

2  Neumann,  Parasites  and  Parasitic  Diseases  of  Domesticated 

Animals,  p.  606. 


IPeterinarg  Diseases  245 

Half  a  million  pullets  are  said  to  perish  every  year 
from  the  disease.1 

IV.     THE    DIGESTIVE    SYSTEM 

Impaction  of  Food.  Domestic  animals  are  pecu- 
liarly liable  to  impaction  of  food  in  various  portions 
of  the  digestive  tract.  The  oesophagus,  the  stomach, 
the  intestines,  the  rectum  may  all  be  affected  by 
this  dangerous  complication,  which  depends  partly 
on  anatomical  peculiarities  and  partly  on  the 
nature  of  food. 

In  cattle  the  region  most  often  attacked  is  the 
rumen  or  paunch,  a  capacious  sac  capable  of 
holding  50  gallons  or  more.  This  rumen  is  physio- 
logically the  first  of  three  cesophageal  dilatations 
(rumen,  reticulum  and  omasum),  the  fourth  com- 
partment or  abomasum  being  the  true  digestive 
stomach. 

Most  cows  fill  their  rumen  with  enormous  quanti- 
ties of  grass,  especially  when  feeding  on  luxuriant 
turf,  and  no  harm  results.  By  means  of  rumination 
and  peristalsis  the  ingesta  are  soon  distributed  to 
other  portions  of  the  alimentary  tract  where  digestion 
proceeds. 

In  the  case  of  a  greedy  feeder,  however,  the 
rumen  is  liable  to  be  distended  to  such  an  extent 
that  the  muscular  walls  are  overstretched  and 
weakened,  while  peristalsis  is  diminished  or  even 
arrested.  The  ingesta  are  then  retained,  instead  of 
being  passed  on,  and  undergo  fermentation  with  the 
production  of  gas  which  causes  further  dilatation 
and  weakness  and  adds  to  the  trouble.  Indeed 
such  impaction,  unless  relieved,  may  end  in  rupture 


Friedberger    and    Frontier,    Veterinary    Pathology,    II., 

P-  753- 


246         IDictous  Circles  in  Bieease 

of  the  rumen  and  speedy  death  (JMatC  XIV.  c). 
Impaction  of  food  in  the  oesophagus  is  also 
frequently  met  with  in  poultry  and  other  birds, 
and  goes  by  the  name  of  ingluvial  stagnation. 
After  an  unusually  heavy  meal  the  food  may  stretch 
the  crop  to  such  an  extent  that  its  muscular  walls 
lose  their  power  of  contracting  and  of  propelling 
the  ingesta.  The  degree  of  distension  may  be 
quite  extraordinary.  Zurn  met  with  a  hen's  crop 
which  with  its  contents  weighed  2  Ibs.  14  oz.  Another 
hen's  crop  had  a  circumference  of  16  inches  and 
a  diameter  of  6  inches.1  The  greater  the  dilatation 
the  weaker  muscular  walls  and  vice  versa.  Occasion- 
ally the  crop  actually  ruptures.2 


1  Friedberger  and  Frohner,  Veterinary  Pathology,  II.,  p.  39. 

2  A   fatal  pathological   Circle  may  be  established  in  fleas 

which  have  been  infected  with  bacillus  pestis  through 
sucking  the  blood  of  infected  rats.  When  such 
fleas  have  swallowed  plague  bacilli  these  bacilli 
produce  solid  jelly-like  colonies  which  multiply 
in  the  stomach  and  are  prevented  from  returning 
to  the  proventriculus  by  an  efficient  valve  which 
remains  closed  during  digestion.  Under  certain 
circumstances,  however,  colonies  grow  in  the  pro- 
ventriculus as  well  as  in  the  stomach,  when  the}*  not 
infrequently  lead  to  complete  blocking  of  the  pro- 
ventricular  valve  by  a  coherent  mass  of  germs. 
As  the  wretched  flea  grows  thirsty  it  sucks  more 
blood  which,  however,  cannot  reach  the  stomach 
and  so  does  nothing  to  quench  thirst,  while  the 
gullet  is  more  and  more  blocked.  In  other  words 
the  more  the  flea  sucks  the  greater  the  obstruction 
and  the  less  can  it  relieve  its  thirst.  Occasionally 
the  obstruction  in  the  proventriculus  undergoes 
autolysis  so  that  the  passage  again  becomes  clear  ; 
otherwise  the  flea  perishes  from  starvation  or  desic- 
cation. Cf.  Bacot  and  Martin,  Journal  of  Hygiene, 
1914  (Plague  Supplement  III.),  p.  423. 


IDeteriuaiy  Bieeaseg  247 

Another  form  of  impaction  is  frequently  met  with 
in  the  horse,  whose  stomach,  owing  to  its  small  size 
and  conformation,  is  peculiarly  liable  to  suffer.  In 
the  first  place  the  cardiac  opening  of  the  oesophagus 
is  small  and  obstructed  by  thick  folds  of  mucous 
membrane.1  Moreover  the  oesophagus  enters  the 
stomach  in  an  oblique  direction,  the  opening  being 
guarded  by  a  powerful  sphincter  which  acts  vigor- 
ously when  the  stomach  contracts  and  tightly 
occludes  the  lower  end  of  the  oesophagus.  It  is 
for  this  reason  that  the  horse  rarely  vomits. 

On  the  other  hand  the  duodenum  just  beyond  the 
pylorus  forms  a  U-shaped  bend,  the  limbs  of  which 
are  readily  compressed,  when  the  stomach  is  over- 
distended.  Thus  both  gastric  orifices  are  easily 
blocked. 

If  a  horse  happens  to  indulge  in  an  unusually 
large  meal,  or  if  fermentation  processes  increase  the 
contents  of  the  stomach  beyond  a  certain  limit, 
there  is  always  a  danger  that  the  ingesta  may 
become  so  tightly  impacted  in  the  stomach  that 
even  vigorous  peristalsis  fails  to  dislodge  the 
mass.  Indeed  the  peristalsis  may,  owing  to  the 
'anatomical  conformation,  actually  prevent  all  escape. 
The  more  vigorous  the  peristalsis  the  less  the  chance 
of  relief  and  vice  versa,  so  that  a  dangerous  impasse 
is  brought  about,  and  the  ingesta  come  to  resemble 
"  a  pudding  boiled  in  a  cloth."  In  course  of  time 
the  muscular  walls  grow  exhausted  and  the  animal, 
unless  relieved,  passes  into  a  state  of  fatal  collapse  ; 
rupture  of  the  stomach  may  be  the  immediate 
cause  of  death. 

Almost  every  part  of  the  intestines  may  be 
occluded  as  a  result  of  the  impaction  of  food,  the 

1  An  illustration  of  the  stomach  is  given  by  Chauveau, 
Comparative  Anatomy  of  Domesticated  Animals, 
P-  457- 


248         \Diciou0  Circles  in  Bieease 


details  being  similar  in  principle  to  those  already 
described.  A  few  words,  however,  may  be  added 
in  reference  to  faecal  impaction  of  the  rectum. 
This  disorder  is  common  in  dogs,  and  may  be  due 
to  dry  and  concentrated  food  associated  with 
insufficient  exercise.  If  these  or  other  causes  have 
led  to  prolonged  coprostasis,  secondary  reactions  are 
frequently  provoked  which  intensify  the  first. 

Another  common  cause  is  the  inability  to  obey 
the  natural  call  at  the  natural  hour,  especially  in 
the  case  of  house-dogs  trained  to  habits  of  cleanliness. 
The  resulting  accumulation  of  faeces  distends  and 
weakens  the  rectum,  enabling  it  to  hold  more 
without  discomfort  and  diminishing  the  power  of 
defaecation.  These  conditions  aid  and  abet  each 
other  and  may  result  in  obstinate  coprostasis. 

Aerophagy.  Aerophagy  or  windsucking  is  fre- 
quently a  self-perpetuating  condition  in  horses,  and 
probably  originates  in  a  gastric  catarrh  attended  by 
flatulence,  which  the  animals  seek  to  relieve  by  the 
swallowing  and  eructation  of  air. 

Owing  to  the  powerful  sphincter  at  the  cardiac 
orifice  and  the  oblique  opening  of  the  oesophagus* 
into  the  stomach  eructations  are  difficult  to  effect, 
unless  something  is  swallowed  at  the  same  time  so 
as  to  relax  the  sphincter.  Consequently  the  horse 
gets  into  the  habit  of  swallowing  air  so  as  to  be 
able  to  belch  up  flatus.  Unhappily,  however,  less 
air  as  a  rule  is  belched  up  than  is  swallowed  and  so 
the  stomach  grows  steadily  larger.  The  greater 
the  distension  the  more  the  horse  resorts  to  air- 
swallowing,  and  so  the  process  gradually  becomes 
habitual.  Flatulence  and  aerophagy  aid  and  abet 
each  other. 

If  the  habit  is  practised  with  great  frequency,  the 
resulting  gastritis  reacts  on  the  general  nutrition. 
In  severe  cases  the  stomach  mav  become  excess- 


IDeterinan?  SHseaeee  249 

ively  distended,  and  this  results  in  a  com- 
plication known  as  gastric  tympany.  The  intra- 
gastric  pressure  may  then  occlude  both  the  oesopha- 
geal  and  pyloric  openings.  So  completely  indeed 
may  both  exits  be  blocked  that  if,  after  death,  the 
gullet  and  the  duodenum  are  divided  the  whole 
inflated  stomach  may  be  removed  without  any 
gas  escaping. 

Intestinal  Tympany.  Allied  to  the  impaction  of 
food  is  another  dangerous  condition,  known  as 
flatulent  colic  or  intestinal  tympany,  which  is 
frequently  due  to  an  animal  having  partaken  of 
some  food  that  readily  ferments  and  evolves  large 
quantities  of  gas,  causing  acute  distension  of  the 
intestinal  walls  and  arrest  of  peristalsis.  The 
more  the  walls  are  stretched  the  weaker  they  grow, 
while  the  weaker  they  grow  the  more  do  they  yield 
to  pressure.  According  to  some  writers  fermentative 
changes  in  the  ingesta  may  also  be  caused  by 
suppression  of  the  secretions  owing  to  ansemia, 
debility,  febrile  diseases  or  intestinal  catarrh. 
Hoare  writes  : 

"  Diminution  or  arrest  of  intestinal  movements 
may  depend  on  suppression  of  the  secretions  quite 
independently  of  actual  obstruction  of  the  bowel, 
and  gives  rise  to  excessive  fermentation  of  the  ingesta. 
Anaemia,  debility,  febrile  diseases,  chronic  intestinal 
catarrh,  etc.,  interfere  with  the  normal  secretions  of  the 
intestines.  Severe  work  immediately  after  a  period 
of  repose,  also  over-exertion,  interfere  with  the  normal 
circulation  of  the  intestine,  and  thus  bring  about 
indigestion  and  the  formation  of  gases.  The  latter 
in  their  turn  distend  the  intestinal  walls,  and  diminish 
the  blood-supply  thereto,  and  also  the  secretions,  so 
that  a  Vicious  Circle  is  thus  established."1 


System  of  Veterinary  Medicine,  II.,  pp.  181,  531. 


25Q         \Dtctou8  Circles  in  SHseaee 

Such  attacks  of  wind  colic  or  tympany  aggravate 
themselves,  and  appear  incurable.  But  happily 
nature  often  wakes  up  to  the  danger  before  it  is 
too  late,  and  by  a  sudden  violent  increase  of  peristal- 
sis expels  the  accumulated  gases  and  breaks  the 
Circle. 

Wool-Eating.  Wool-eating  or  mallophagia  be- 
longs to  a  group  of  habit  Circles  of  which  a  variety 
of  examples  are  met  with.  In  the  sheep  the  first 
impulse  to  wool-eating  arises  in  some  slight  dyspepsia 
or  want  of  food  which  creates  the  desire  to  nibble  at 
something,  since  such  nibbling  gives  satisfaction. 
Hence  the  trick  is  repeated  and  in  course  of  time 
becomes  habitual.  The  grooves  of  habit  in  the 
nervous  system  wear  more  and  more  deeply  ;  the 
nerve  centres  grow  more  and  more  labile,  so  that 
repetition  occurs  on  less  and  less  provocation. 

Another  Vicious  Circle  is  associated  with  pica  or 
perversion  of  the  appetite,  which  probably  results 
from  some  dyspeptic  condition  which  creates  an 
abnormal  and  perverted  sense  of  hunger.  The 
affected  animal  will  eat  almost  anything  that  offers, 
e.g.  clay  or  even  its  own  faeces.  Such  a  diet  natur- 
ally increases  the  primary  dyspepsia.  In  course  of 
time  a  chronic  flatulence  results  and  gives  rise  to 
a  pot-bellied  condition. 

V.     THE       GENITOURINARY       SYSTEM 

Hydronephrosis.  Hydronephrosis  is  a  serious 
and  not  uncommon  disease  in  cattle  and  other 
domestic  animals.  The  disorder  may  be  primarily 
due  to  unusual  mobility  of  the  kidney  as  a  result 
of  which  the  ureter  is  kinked,  followed  by  an 
accumulation  of  urine  in  the  renal  calyces.  Such 
accumulation  causes  an  increased  weight  of  the 
organ,  a  further  descent  in  the  abdomen  and  further 
obstruction  to  the  escape  of  urine.  Thus  retention 


lDeterinan>  Diseases  251 

begets  retention.  In  course  of  time  the  pressure  of 
retained  urine  may  lead  to  hydronephrosis  followed 
by  gradual  destruction  of  renal  tissue.  Indeed 
the  kidney  may  be  converted  into  an  enormous 
cyst  whose  urinary  functions  have  been  lost. 

Urinary  Calculi.  Urinary  calculi  may  be  associ- 
ated with  similar  Vicious  Circles  as  in  man,  and 
the  details  given  above  will  apply. 

In  the  domestic  animals,  however,  some  peculiar 
anatomical  configuration  may  establish  dangerous 
correlations  of  special  interest.  An  example  is 
met  with  in  the  bull  which  of  all  animals  suffers 
most  from  urethral  calculi  (JMate  XIV.  d).  The  rea- 
son is  to  be  found  in  the  small  lumen  and  extra- 
ordinary twist  of  the  urethra  which  readily  arrest 
the  progress  of  any  calculi  that  descend  from  the 
bladder.  Not  only  is  the  urethral  orifice  narrowed 
to  |-  inch,  but  the  duct  takes  an  S-shaped  bend 
which  cannot  be  traversed  by  the  catheter,  and  at 
which  even  small  calculi  may  be  retained  and  cause 
obstruction  of  urine.1  Such  obstruction,  if  complete, 
may  cause  rupture  of  the  bladder  and  speedy  death. 
But  if  the  obstruction  is  not  complete  the  calculus 
forms  a  nucleus  round  which  accretions  accumulate. 
The  larger  the  nucleus  the  more  rapidly  it  grows 
and  vice  versa.  Thus  an  obstruction  that  at  first 
was  only  partial  may  become  complete  and  prove 
fatal. 

A  very  similar  S-shaped  curve  is  present  in  the 
urethra  of  the  ram,  another  animal  that  suffers 
much  from  calculi. 

Milk  Fever.  Milk  fever  is  not  uncommon  in 
milch  cows  and  is  often  complicated  by  dangerous 
circular  reactions.  The  milk,  after  being  formed 


!The  S-shaped  twist  is  well  illustrated  by  M  oiler.     Opera- 
tive Veterinary  Surgery,  p.  321. 


252         IDicfous  Circles  in  Disease 

in  the  glandular  tissues,  flows  into  the  milk  ducts 
which  convey  it  to  a  large  cavity  at  the  base  of  the 
teat  termed  the  galactophorous  sinus,  there  being 
one  galactophorous  sinus  and  teat  for  each  division 
of  the  udder.  From  the  galactophorous  sinus 
a  narrow  duct  lined  with  mucous  membrane  leads 
to  the  open  air. 

The  causes  of  milk-fever  are  still  obscure,  but  there 
is  probably  in  many  attacks  some  infection  by 
micro-organisms,  followed  by  inflammation  of  the 
parenchyma  of  the  udder  as  well  as  of  the  galacto- 
phorous sinus,  with  narrowing  of  the  effluent  duct 
and  stagnation  of  milk.  Owing  to  this  stagnation 
the  milk  tends  to  undergo  decomposition,  and  this 
further  aggravates  the  primary  inflammation  and 
irritation. 

In  some  cases  the  inflammation  leads  to  gradual 
narrowing  of  the  duct  followed  by  stagnation, 
putrefaction  and  further  obstruction,  eventually 
resulting  in  a  completely  closed  abscess  cavity. 
The  severity  of  the  disease  varies  with  the  virulence 
of  the  infective  organisms  and  with  other  conditions, 
but  a  lethal  result  is  not  uncommon. 

Egg-Binding.  Another  circular  process  is  associ- 
ated with  egg-binding,  and  is  due  to  an  egg  distend- 
ing the  oviduct  to  such  a  degree  that  the  muscular 
walls  are  thinned  and  lose  their  power  of  con- 
traction. Such  paralysis  arrests  all  progress,  and 
this  in  turn  perpetuates  the  distension  and  weak- 
ness (JplatC  XIV.  e).  Moreover  the  arrested  pro- 
gress of  the  egg  causes  the  bird  to  strain  violently 
and  this  causes  swelling  and  inflammation,  tending 
to  increased  obstruction.1  In  some  cases  the  oviduct 
ruptures  and  allows  the  egg  to  pass  into  the  peritoneal 
cavity,  where  dangerous  peritonitis  is  set  up. 

1L/aw,  Veterinary  Medicine,  III.,  p.  295. 


lt)eterinan>  Bieeaeee  253 

VI.    THE    CUTANEOUS    SYSTEM 

Parasitic  skin  affections,  such  as  scabies  and 
ringworm,  are  frequently  complicated  by  self -per- 
petuating conditions.  The  variety  of  such  disorders 
is  so  great  that  only  one  or  two  examples  can  be 
given,  but  they  suffice  to  illustrate  the  principle 
that  the  parasite  is  able  to  secure  its  own  diffusion 
by  means  of  the  irritation  excited  by  its  presence 

(BMate  xiv.  f). 

A  common  example  is  presented  by  the  sarcoptes 
scabiei  which  infests  the  dog.  This  acarus  sets  up 
severe  pruritus  which  the  dog  seeks  to  relieve  by 
scratching  and  rubbing.  As  a  result  the  paws 
become  infected  with  the  acari  or  their  ova,  and 
transfer  them  to  other  parts  of  the  body  where 
fresh  outbreaks  of  the  -scabies  are  started. 

Three  forms  of  acarus  are  found  in  the  sheep, 
but  the  most  important  variety  is  the  dermodectes 
communis  which  gives  rise  to  the  dermodectic  mange. 
In  some  countries  a  majority  of  the  sheep  are 
affected. 

The  parasites  chiefly  attack  parts  of  the  body 
that  are  covered  with  wool,  since  this  affords  them 
protection.  Abundant  vesicles  and  pustules  are 
formed,  giving  rise  to  secretions  which  glue  the 
wool  together  and  create  large  scabs.  The  eruption 
is  often  accompanied  by  violent  itching  which 
compels  the  animal  to  rub  and  scratch  itself.  By 
this  means  the  acari  are  readily  transferred  to 
fresh  areas  where  they  spread  the  disease.  The 
scabs  also  favour  the  multiplication  of  the  acari, 
since  such  shelter  supplies  food,  warmth  and  pro- 
tection. 

Another  cutaneous  disorder  in  sheep  is  due  to  the 
tinea  tonsurans  which  leads  to  felting  of  the  wool 
beneath  which  scabs  form.  Here  also  considerable 
itching  may  be  caused  by  the  infecting  fungus,  and 
such  itching  leads  to  the  transference  of  spores  to 


254          Didous  Circles  in  Biscase 

healthy  areas  by  means  of  the  feet  or  lips. 

Birds  often  suffer  from  the  form  of  ringworm 
known  as  the  achorion  schonleinii,  which  gives 
rise  to  favus  or  fowl  mange.  The  eruption  frequently 
starts  on  the  comb  or  ears,  whence  it  gradually 
spreads  until  the  entire  comb  and  even  the  whole 
body  is  covered  with  a  mouldy  deposit.  The 
secondary  itching  provokes  scratching  and  is  largely 
responsible  for  the  rapid  diffusion  of  the  spores. 

This  brief  account  of  some  Vicious  Circles  in 
Veterinary  diseases  will,  it  is  hoped,  suffice  to 
illustrate  their  importance.  There  is  ample  scope 
for  a  volume  dealing  with  this  morbid  process  in 
zoo-pathology,  and  especially  with  the  best  methods 
of  arresting  it. 


Chapter  Siyteen 


PLANT    DISEASES 

|N  the  Chapter  devoted  to  Aetiology  the 
Vicious  Circle  in  animal  and  plant  diseases 
was  attributed  to  a  disturbance  of  the 
physiological  correlations  present  in  all 
organised  living  things.  There  is,  how- 
ever a  striking  difference  in  the  morbid  process  as  met 
with  in  animals  and  in  plants.  In  the  former  owing 
to  the  higher  differentiation  of  organs  numerous 
specific  circuli  vitiosi  are  met  with.  A  specific 
lesion  giyes  rise  to  a  secondary  specific  lesion  which 
in  turn  aggravates  the  primary  one,  and  this  endless 
chain  can  be  studied  link  by  link.  * 

Future  research  may  reveal  similar  conditions  in 
plant  pathology.  But  at  present  specific  reactions  of 
morbid  processes  have  been  but  little  studied  in 
plants.  On  the  other  hand  the  general  principle  of  the 
Vicious  Circle  is  in  universal  operation.  lowered 
resistance  due  to  one  or  more  adverse  circumstances 
renders  the  plant  susceptible  to  some  injurious 
factor,  such  as  parasitic  infection,  which  in  its  turn 
further  lowers  resistance.  The  death  of  plants 
frequently  results  from  this  morbid  process. 

Lowered  resistance  may  be  due  to  a  great  variety 
of  causes.  Amongst  them  are  unsuitability  of  soil, 
temperature  or  climate,  and  excess  or  deficiency 
of  water.  According  to  recent  researches  by  Appel2 

1  Cf.  also  Plant  Disease  and  the  Vicious  Circle,  by  J.B.H., 

/.  Royal  Hort.  S.   (1919),  XLHL,  p.  309. 

2  Gardener's  Chronicle,  1915,  II.,  p.  322, 

255 


256          IDlcioue  Circles  in  Disease 

excess  of  air  in  the  tissues  associated  with  insuffi- 
ciency of  water  acts  in  the  same  direction. 

Another  cause  is  immaturity  of  tissue.  The  epider- 
mis in  early  life  is  both  tender  and  thin,  and  may  be 
penetrated  by  bacteria  or  fungi  that  are  power- 
less to  injure  plants  whose  epidermis  has  become 
cuticularised  or  replaced  by  cork.  On  the  other 
hand  advanced  age  also  predisposes  to  infection. 
In  young  coniferous  trees  well  provided  with  resin 
canals  injuries  of  the  cortex  are  at  once  sealed  by  an 
exudation  of  turpentine  and  thus  protected  from 
wound  fungi,  while  in  older  trees  turpentine  and 
resin  are  less  freely  exuded  as  styptics.  Again 
wounds  are  more  slowly  occluded  by  callus  in  old 
age  than  in  youth.  Such  predisposing  factors 
enable  organisms  successfully  to  effect  an  entrance, 
and  further  to  weaken  the  host. 

Parasitic  invaders  may  abstract  their  food  from 
the  host-plant  by  various  methods.  Some  ramify 
in  the  inter-cellular  spaces  and  middle  lamellae  ; 
others  send  haustoria  into  the  actual  cells.  Many 
secrete  enzymes  or  toxins  which  destroy  cells  or 
cell-walls,  the  materials  of  which  then  promote 
further  growth  and  proliferation  of  the  parasites. 
Hence  fresh  enzymes  or  toxins  are  secreted  for  the 
destruction  of  remoter  cells,  which  in  their  turn 
fall  a  prey  to  the  ever-spreading  invader.  The 
morbid  process  vires  acquirit  eundo. 

The  effects  of  injurious  circular  reactions  may  be 
briefly  discussed  under  three  headings  : 

I.     The  Perpetuation  of  Disease 
II.    The  Destruction  of  Organs 
III.     The  Termination  of  Life 

These  groups,  however,  are  by  no  means  sharply 
defined  ;  diseases  placed  in  I.  and  II.  may  under 
exceptional  conditions  prove  fatal,  while  diseases 


plant  IDiscascs 


257 


&  x~  ~^\^ 

*/          V,      Jfc 


fe 


(a)  THE  PERPETUATION  OF  DISEASE 


at* 
/ 
J» 


^ 


U0\V 
(b)  THE  DESTRUCTION  OF  ORGANS 


(c)  THE  TERMINATION  OF  LIFE 

plate  XV.— Circles  aseociateb  with 
plant  2)ieea0e0. 


25$          HMcious  Circles  in  2Hgease 

placed  in  III.  may  be  so  chronic  as  scarcely  to  shorten 
the  duration  of  life.1 

I.  THE  PERPETUATION  OF  DISEASE 
The  perpetuation  of  a  disease  through  insufficient 
chlorophyll  assimilation  has  already  been  referred 
to  (p.  3).  In  other  cases  the  morbid  condition  may  be 
initiated  by  living  organisms  (JMatC  XV.  a).  Both 
the  true  fungi  as  well  as  Schizomycetes  (Bacteria) 
and  Myxomycetes  (Slime  Fungi)  may  be  concerned. 

Peridermium  Pini.  A  striking  example  may  be 
found  in  the  case  of  pine-blister  caused  by  the 
Coleosporium  Senecionis  (Peridermium  Pini,  var. 
corticola),  a  fungus  which  attacks  the  cortex  of  the 
Scotch  and  Wey mouth  pines  amongst  others.  The 
hyphse  grow  in  between  the  green  cells  of  the  cortex 
as  well  as  in  the  bast-tissues,  and  may  even  penetrate 
the  medullary  rays  and  resin-canals.  Other  hyphse 
pierce  the  cells,  consume  the  starch  and  other  food- 
stuffs, and  cause  a  serious  loss  of  resin  which  both 
soaks  into  the  wood  and  exudes  from  the  bark. 
This  loss  of  resin  involves  a  serious  impairment  of 
vitality.  Moreover  the  effusion  of  turpentine  into 
the  wood  interferes  with  conduction  of  sap  in  these 
tissues  and  lowers  the  nutrition  of  the  tree,  especially 
above  the  point  of  attack,  since  the  flow  of  sap  is 
checked. 

Meanwhile  the  parasite  nourishes  itself  on  the 
juices  which  it  has  liberated  and  on  the  contents 

1Many  beneficent  circular  reactions  occur  both  in  plants 
and  in  animals.  Thus  in  the  healthy  plant  the 
leaves,  the  roots  and  other  organs  are  reciprocally 
dependent  on  each  other  and  "  enable  the  ideally 
correlated  system  to  go  on  working  at  maximum 
energy  "  (Ward,  Disease  in  Plants,  p.  94).  A  more 
specific  process  of  reciprocation  is  associated  with 
leguminous  plants  and  the  presence  of  nitrifying 
bacilli.  More  vigour  :  more  galls  :  more  nitrogen  : 
more  vigour — constitute  the  sequence. 


[plant  3Di0eases  259 

of  the  cells  it  has  invaded.  Thus  a  struggle  takes 
place  which  may  last  for  many  years.  If  the  tree 
is  vigorous  it  may,  by  the  diversion  of  metabolic 
material,  form  sufficient  cork  to  shut  in  and  suffocate 
its  enemy.  But  as  a  rule  the  invader  extends  his 
ravages  and  converts  a  robust  thriving  tree  into 
a  dwarfed  sickly  one.  The  more  the  parasite  can 
arrest  the  flow  of  sap  and  the  greater  the  loss  of 
resin  the  more  is  vitality  impaired,  and  the  less 
the  vitality  the  more  rapid  the  progress  of  the 
invader.  Cause  and  effect  aid  and  abet  each  other, 
and  the  result  is  a  chronic  invalidism  of  an  enormous 
number  of  trees  that  are  attacked  by  this  disastrous 
disease. 

A  similar  process  is  frequently  observed  as  a  result 
of  bacterial  invasion.  Hrwin  F.  Smith  has  described 
a  number  of  leaf-spot  diseases  in  which  the  parasite 
penetrates  through  stomata  in  the  unbroken  leaf 
and  stem  surface,  and  multiplies  in  the  substomatic 
chamber,  causing  a  local  destruction  of  tissue. 
Thus  Bacterium  phaseoli  is  responsible  for  the  spot 
disease  of  beans,  Bacterium  maculicolum  for  the  spot 
disease  of  cauliflowers,  and  other  examples  have 
been  observed.  Leaf  spots  are  often  slow  in  their 
progress  and  confined  to  small  areas,  the  reason 
probably  being  that  the  vascular  system  is  not 
invaded.  Nevertheless  the  bacteria  weaken  or  de- 
stroy the  cells  of  their  host.  With  increasing  supplies 
of  food  and  a  nidus  rendered  alkaline  by  their  own 
excretions  the  bacteria  multiply  more  and  more, 
unless  indeed,  as  sometimes  happens,  the  host  can 
arrest  the  process  by  separating  the  diseased  from  the 
healthy  tissues  by  the  formation  of  a  corky  layer. 

II.     THE    DESTRUCTION   OF    ORGANS 
Another  result  of  an  injurious  circular  reaction  is 

the  destruction  of  an  organ  either  by  a  non-living 

or  a  living  agency. 
The  effect   of    a  non-living  agency  is  illustrated 


260         iDicious  diccles  in  Disease 

by  the  premature  shedding  of  leaves  or  of  twigs 
which  may  be  thrown  off  in  great  numbers  as  a 
result  of  organic  tissue  changes  (plate  XV.  b). 

The  disorder  is  most  often  observed  in  the  case 
of  leaves,  and  is  initiated  by  an  impairment  of 
assimilation  and  transpiration  processes,  as  a  result 
of  which  the  suction  force  by  which  under  healthy 
conditions  the  sap  is  drawn  up  is  lost.  Conse- 
quently the  sap  accumulates  in  the  basal  leaf  zone 
through  which  the  line  of  cleavage  ultimately  passes, 
and  which  becomes  excessively  turgid  with  osmotic 
materials.  This  turgor  stimulates  to  premature 
activity  the  dormant  cells  of  the  abscission  layer  ; 
the  partition  wall  between  adjacent  cells  swells  and 
a  process  of  dissociation  is  inaugurated.  The  effect 
is  a  further  impairment  of  vitality  of  the  leaves, 
culminating  in  complete  detachment.  To  quote 
Sorauer  :  "  Every  premature  shedding  of  leaves 
is  due  to  a  disturbed  equilibrium  in  the  distribution 
of  turgor."1  In  other  words  the  process  of  premature 
cleavage  is  due  to  an  arrest  of  metabolic  activity 
causing  pathological  turgor  at  the  basal  zone, 
followed  by  a  progressive  loss  of  activity. 

A  similar  process  accounts  for  the  premature 
shedding  of  twigs  or  shoots,  which  may  occur  as 
early  as  July.  The  oak  and  the  poplar  are  frequently 
affected,  the  ground  being  in  some  cases  thickly 
strewn  by  the  detached  twigs. 

The  destruction  of  organs  may  also  be  due  to 
the  attacks  of  parasites,  some  of  which  display  a 
preference  for  certain  organs,  such  as  leaves,  twigs, 
tubers  or  buds.  A  lowered  state  of  vitality  pre- 
disposes to  such  parasitic  invasion  which  then 
further  lowers  nutrition,  culminating  in  the  total 
destruction  of  the  organs. 

Lophodermium  Pinastri.  As  an  example  of  a 
parasitic  leaf-shedding  disease  may  be  mentioned 

1  Pflanzenkrankheiten,  I.,  p.  357. 


plant  Diseases  261 

the  Pine  Needle-cast  caused  by  the  fungus  Lophoder- 
mium  Pinastri,  also  called  the  Pine  Leaf -scurf  or 
leaf -shedding  fungus. 

The  disease  chiefly  attacks  the  young  and  tender 
leaves  of  the  Scots  and  Austrian  Pines  and  other 
Conifers,  and  may  cause  many  of  their  leaves 
suddenly  to  wilt  and  drop.  The  needles  when  first 
attacked  are  merely  speckled  with  brown  spots 
containing  the  mycelium  of  the  fungus  ;  but  in  the 
following  year  they  wither,  turn  red  or  brown  and 
die  off  in  hundreds.  This  loss  of  leaves  seriously 
weakens  the  plants  and  thus  hastens  the  progress 
of  the  disease.  The  greater  the  loss  of  foliage  the 
less  the  power  of  resisting  infection.  It  is  for  this 
reason  that  the  parasite  is  most  destructive  in  shut-in 
valleys  or  low-lying  situations  where  the  trees 
possess  least  vitality  and  consequently  succumb 
most  readily. 

The  destruction  of  twigs  is  often  brought  about 
by  infection  with  the  Botrytis  Douglasii. 

Ustilago.  Another  illustration  of  a  similar  pro- 
cess may  be  found  in  the  operations  of  the  cereal 
smuts  (Ustilago),  which  attack  such  grains  as  are 
rendered  liable  to  infection  by  lowered  vitality.  The 
smuts  reduce  the  ovules  to  a  black  powdery  mass  of 
spores  which  are  carried  away  on  the  wind  or  other- 
wise dispersed,  leaving  nothing  but  the  bare  axis 
on  which  the  flowers  were  originally  situated. 

III.    THE  TERMINATION  OF  LIFE 

Many  examples  might  be  given  of  the  destruction 
of  plants  as  a  result  of  a  Vicious  Circle.  It  was 
formerly  supposed  that  disease  in  animals  was 
usually  caused  by  bacteria,  while  diseases  in  plants 
was  almost  invariably  due  to  fungi.  But  recent 
research  has  shewn  that  even  in  plants  many 
bacterial  diseases  occur.  Both  Schizomycetes  and 
Myxomycetes  may  be  concerned  ((Mate  XV.  c). 


262          iDtctous  Circles  in  Disease 

E.  F.  Smith  thus  describes  the  process  by  which 
bacteria  can  provide  for  their  own  indefinite  multi- 
plication, when  once  a  foot-hold  has  been  secured  : 
"  Enzyms,  toxines,  acids  and  various  by-products 
of  the  bacterial  growth  also  undoubtedly  play  their 
part,  weakening  the  cells  of  the  host  or  destroying  them 
outright.  With  increasing  supplies  of  food,  and  a 
nidus  rendered  suitably  alkaline  by  their  own  excre- 
tions, the  bacteria  multiply  more  and  more,  obstructing 
some  tissues  and  dissolving,  displacing  and  crushing 
others.  The  tissues  are  poisoned  more  and  more  by 
absorption  of  the  continually  increasing  quantity  of 
bacterial  by-products,  cells  are  separated,  cell-walls 
are  softened  or  dissolved,  protoplasm,  amids,  acids, 
starch,  and  sugars  are  consumed.  Beginning,  therefore, 
with  a  tiny  superficial  nidus  in  an  open  wound,  a 
facultative  parasite  gradually  burrows  its  way  into 
the  deeper  tissues,  forming  closed  cavities  or  open 
wounds,  and  finally  destroying  the  entire  plant  or 
limiting  its  operations  to  special  organs,  as  the  case 
may  be.  Such  is  the  impression  one  gets  from  a  study 
of  wound-infections."1 

Two  fatal  diseases  may  now  be  described,  one  due 
to  a  fungus  and  one  to  a  bacillus. 

Dasyscypha  Willkommii.  The  well-known  larch 
canker,  associated  with  the  invasion  of  the  Dasy- 
scypha Willkommii,  is  an  example  of  a  fungoid 
disease  which  is  responsible  for  the  loss  of  an  enorm- 
ous number  of  trees  in  our  woodlands.  The  larch 
is  indigenous  in  the  Alps  where  there  is  a  long 
winter  season,  followed  by  a  short  or  no  spring, 
and  by  a  short  hot  summer.  Owing  to  the  rapid 
transition  from  winter  to  summer  the  larch  buds 
open  very  rapidly  when  once  they  start.  Hence 
the  period  during  which  the  foliage  is  young  and 
tender,  and  susceptible  to  attack  is  very  short,  since 
the  tree  passes  rapidly  into  its  summer  state  with 
its  increased  power  of  resistance.  When,  however, 
the  larch  is  planted  in  such  a  country  as  England, 

1  Bacteria  in  Relation  to  Plant  Diseases,  II.,  p.  51. 


plant  2>tsea0e0  263 


with  a  mild  winter  and  a  long  and  damp  spring, 
the  period  of  foliation  extends  over  six  or  eight  weeks, 
instead  of  two  as  in  the  Alps,  so  that  insects  and 
fungoid  enemies  have  a  much  longer  period  during 
which  to  do  damage. 

The  great  enemy  of  the  larch  is  the  Dasyscypha 
Willkommii,  which  effects  a  lodgment  in  wounds 
in  the  young  leaves  and  shoots  made  by  plant  lice 
(Chermes  laricis)  or  the  mining-moth  (Coleophora 
laricella),  or  by  some  other  agency  which  breaks  the 
surface  continuity.  In  such  a  wound  the  spores 
find  a  favourable  nidus,  whence  the  mycelium 
penetrates  into  the  cortex  during  the  quiescent 
period  of  winter. 

If  the  tree  has  sufficient  vitality,  it  may  succeed 
during  the  period  of  active  growth  in  cicatrising 
the  canker-spot,  by  surrounding  the  blister  by  a 
tough  corky  layer  and  thus  arresting  its  progress. 

But,  under  less  fortunate  conditions,  when  autumn 
returns  the  mycelium  penetrates  further  into  the 
cambium  and  enlarges  the  canker-spot.  Event- 
ually it  reaches  the  wood  and  interferes  with  the 
flow  of  sap.  The  further  the  invader  advances,  the 
more  is  the  resisting  power  of  the  host-plant  weakened, 
while  such  loss  of  resistance  quickens  the  progress 
of  the  fungus.  In  course  of  time  the  tree  sickens 
and  dies. 

Bacterium  Hyacinthi.  The  yellow  bacteriosis 
of  hyacinth  bulbs  may  serve  as  an  example  of 
a  specific  and  fatal  bacterial  disease,  due  to 
the  Bacterium  Hyacinthi.  Healthy  bulbs  are  rarely 
attacked  ;  but  if  a  wound  or  other  injury  has 
impaired  vitality  infection  readily  follows.  The 
sequence  may  thus  be  represented  : 

Growth  of  Bacteria  *» — >  Breaking  up  of  living  Cells 
Supply  of  Nutriment  to  Bacteria 


264          IDicious  Circles  in  Disease 

In  the  early  stage  of  bulb  infection  the  disease  is 
confined  to  the  vascular  bundles,  from  one  to  fifty 
of  these  being  yellow  and  full  of  bacterial  slime  ; 
but  at  a  later  stage  the  disease  spreads  to  the 
intervening  parenchyma,  and  finally  the  whole 
bulb  is  destroyed. 

These  examples  of  injurious  circular  reactions  in 
phyto-pathology  might  be  indefinitely  multiplied  ; 
but  they  suffice  to  indicate  the  operation  of  a 
wide-spread  principle.  The  process  belongs  to  those 
fundamental  biological  phenomena  which  are  com- 
mon to  both  the  higher  animals  and  plants.  Within 
the  limits  of  health  organisation  is  of  unquestioned 
advantage.  On  the  other  hand  the  liability  to 
pernicious  and  reciprocal  correlations  is  a  serious 
penalty  paid  for  such  organisation,  when  physiological 
processes  are  disturbed  by  disease. 

The  simpler  organisation  of  plants  probably 
explains  why  this  complication  of  disease  is  so  much 
less  specific  than  it  is  in  zoo-pathology.  Another 
reason  is  that  in  the  animal  every  organ  is  fully 
developed  and  performs  its  functions  to  the  utmost, 
while  in  the  plant  there  are  always  present  the 
rudiments  of  new  organs  as  well  as  accumula- 
tions of  reserve  materials,  and  each  of  these 
provisions  can  assist  in  making  good  any  failure 
of  functional  activity.  A  further  explanation  may 
be  found  in  the  more  intimate  union  of  cells  in  the 
animal  as  compared  with  the  plant,  allowing,  as  it 
does,  of  closer  inter-dependences. 

Apart  from  these  reasons,  however,  there  can  be 
little  doubt  that  with  the  growth  of  our  knowledge  of 
correlations  in  plants  many  examples  of  specific 
circuit  vitiosi  will  be  revealed.  A  further  proof 
will  thus  be  supplied  of  the  essential  unity  in  the 
laws  governing  animal  and  vegetable  pathology. 


Chapter  Seventeen 


THE   VICIOUS    CIRCLE    AS    A    CAUSE 
OF    DEATH 


ICIOUS  Circles  may  exert  an  injurious 
influence  in  three  directions  :  the  per- 
petuation of  disease  ;  the  destruction  of 
organs  j1  the  ending  of  life.  Numerous 
examples  of  each  of  these  effects  have 
been  given  in  the  preceding  pages.  But  it  may  be 
useful  to  emphasise  the  fatal  influence  of  this 
morbid  process -and  to  shew  how  common  is  mors 
ex  circulo  vitioso.  The  expectation  of  life  is  materially 
affected  by  this  complication  of  disease. 

It  has  been  pointed  out  above  that  the  Vicious 
Circle  usually  arises  through  disorder  in  an  organ 
or  part  of  an  organ  creating  disorder  in  other  organs 
or  parts  of  organs,  the  reaction  of  which  aggravates 
the  primary  disorder.  The  evil  is  therefore  one  of 
the  penalties  paid  for  specialisation  of  structure  and 
function,  and  is  only  encountered  in  the  higher  mem- 
bers of  the  animal  and  vegetable  kingdoms  which  have 
reached  a  certain  stage  in  organic  evolution.  The 
gravity  of  the  complication  naturally  depends  on  the 
importance  of  the  organs  affected  and  on  the  nature 
of  the  morbid  process  at  work. 

1  As  illustrations  of  the  destruction  of  organs  may  be  men- 
tioned the  brain  in  hydrocephalus,  the  eye  in 
glaucoma,  the  kidney  in  hydronephrosis  and  the 
lung  in  tuberculosis. 

265 


266          iDictoue  Circles  in  Di0ea0e 

Many  years  ago  Bichat  sought  to  distinguish 
between  death  by  the  heart,  death  by  the  lungs  and 
death  by  the  brain.1  Such  a  classification  cannot 
be  accepted'  in  the  light  of  modern  pathology, 
since  we  know  that,  by  whichever  gate-way  danger 
first  approaches,  actual  death  results  from  the 
arrest  of  all  the  vital  functions.  Nevertheless,  as  a 
matter  of  convenience,  we  may  associate  deaths  with 
the  same  triumvirate  of  vital  organs  and  describe  : 
I.  Deaths  associated  with  the  Vascular 

System 
II.     Deaths  associated  with  the  Respiratory 

System 
III.     Deaths    associated    with   the    Nervous 

System 

Wynn  Westcott  found  that  the  chief  factor  in 
sudden  death  was  cardiac  in  60  per  cent.,  cerebral 
in  30  per  cent,  and  pulmonary  in  10  per  cent.2 

I.     DEATHS  ASSOCIATED   WITH  THE 
VASCULAR   SYSTEM 

Heart  Failure.  Heart  failure  ranks  as  one  of 
the  commonest  modes  of  death,  and  occurs  under 
a  great  variety  of  circumstances  (JMatC  XVI.  a).  For 
example,  acute  cardiac  dilatation  may  weaken 
the  coronary  circulation  to  such  a  degree  that 
insufficient  blood  reaches  the  myocardium  to  allow 
of  its  continued  activity.  The  less  the  blood 
supplied  to  the  myocardium  the  feebler  the  systole 
and  vice  versa.  This  sequence  probably  caused  the 
death  of  the  famous  soldier  Eucles  who  raced  to 
Athens  with  the  news  of  Marathon,  shouting 
Xcupcre,  xa'LP°lJ'(LV>  and  dropped  dead  on  arrival.  The 
prolonged  strain  led  to  high  blood-pressure,  to 
cardiac  dilatation,  to  inadequate  coronary  circula- 

^echerches  sur  la  Vie  et  la  Mort. 
2 British  Med.  /.,  1908,  I.,  p.  491. 


She  Circle  as  a  Cause  of  Death     267 


(a)  DEATH  FROM  CARDIAC 
DILATATION 


(b)  DEATH  FROM  CARDIAC 
RUPTURE 


(c)  DEATH  FROM  ASPHYXIA 


(d)  DEATH  FROM 
PULMONARY  HEMORRHAGE 


(e)  DEATH  FROM  CEREBRAL 
HEMORRHAGE 


(f)  DEATH  FROM  SHOCK 


plate  xvi.— £be  Circle  as  a  Cause 
of  Death. 


268  Dicious  Circles  in  Disease 


tion,   to   inadequate   nutrition  of  the  myocardium, 
to  further  dilatation  and  finally  to  syncope. 

Death  frequently  results  from  coronary  obstruction 
due  to  sclerosis,  a  condition  which  accounts  for  the 
death  of  many  elderly  persons,  to  whom  the  end 
comes  like  a  "  bolt  from  the  blue."  The  morbid 
process  has  probably  been  in  progress  for  years, 
until  a  stage  is  reached  when  the  lumen  of  one  or 
both  coronary  arteries  is  seriously  narrowed  by 
degenerative  processes.  The  exaggerated  vis  a 
fwnte  requires  an  increased  vis  a  tergo,  if  life  is  to 
continue,  whereas  the  diminished  coronary  blood- 
supply  actually  weakens  the  force  of  the  systole. 
In  other  words  the  defective  coronary  circulation 
and  the  myocardiac  weakness  progressively  aggra- 
vate each  other,  until  death  closes  the  scene.  Fatal 
angina  pectoris  may  be  due  to  this  sequence  of  events, 
some  unusual  effort,  with  its  extra  requirement  of 
blood,  proving  the  proverbial  last  straw.  Syncope 
may  be  instantaneous,  coeval  with  a  single  pang, 
attitude  and  expression  remaining  perfectly  placid. 
No  blood,  no  systole  here  represents  the  mechanism 
of  death. 

In  other  cases  the  fatal  issue  may  be  due  to  the 
reciprocal  action  of  cardiac  venous  engorgement 
and  cardiac  malnutrition.  As  the  heart  grows 
incompetent,  the  coronary  veins  are  the  first  to 
feel  the  back  pressure  and  their  congestion  inter- 
feres with  the  circulation  through,  and  therefore 
with  the  nutrition  of,  the  heart. 

S.  West  thus  describes  the  pathological  sequence  : 
"  If  the  nutrition  is  thus  affected,  the  muscle  will  be 
weak,  and  the  heart  will  dilate.  This  weakness  still 
further  increases  the  venous  congestion,  which  in  turn 
increases  the  weakness  again.  So  a  Vicious  Circle 
is  established,  and  an  explanation  given  to  the  extra- 
ordinary rapidity  with  which  the  heart  failure  often 
develops  when  once  it  has  set  in."1 

1  British  Med.  /.,  1905,  II.,  p.,   1032. 


Circle  as  a  Cause  of  Death       269 

Another  dangerous  condition  is  the  paradoxical 
association  of  an  over-strained  and  weakened  heart 
with  an  abnormally  high  blood-pressure.  The  slow- 
ing of  the  circulation  tends  to  produce  anaemia  of  the 
medullary  centres,  which  respond  by  inducing  vaso- 
constriction  in  order  to  bring  about  increased 
pressure  and  so  to  secure  a  larger  quantity  of 
blood.  The  already  weakened  heart  is  thus  called 
upon  for  a  supreme  effort,  and  the  weaker  it  is  the 
more  do  the  imperious  medullary  centres  insist  on 
more  blood.  At  length  comes  a  moment  when  the 
pressure  within  the  weakened  ventricle  is  raised 
beyond  endurance.  Suddenly,  in  accordance  with  the 
"  all  or  nothing  "  law,  the  heart  stops  in  diastole. 
The  process  is  thus  graphically  represented  by 
Hirschfelder  :  1 

Cardiac    weakening 


Increased  cardiac  effort       Slowed  circulation 
High  blood-pressure         through  medulla 

Vaso-constriction 

Some  fatal  correlations  also  occur  in  connection 
with  valvular  disease.  For  example,  an  aortic 
valve  may  rupture  during  violent  exertion,  the 
regurgitating  blood  throwing  a  sudden  and  severe 
strain  on  the  heart,  which  has  no  time  to  accommo- 
date itself  to  altered  conditions.  Dilatation  of  the 
ventricle  follows,  with  a  feebler  systole,  increased 
regurgitation  and  in  severe  cases  immediate  death. 

Amongst  the  various  forms  of  chronic  valvular 
disease,  stenosis  and  incompetence  of  the  aortic 
orifice,  associated  with  dilatation  of  the  ventricle, 

Diseases  of  the  Heart  and  Aorta,  p.  315, 


270 IDtcioug  Circles  in  Disease 

most  frequently  lead  to  death.  After  perhaps 
many  years  of  fairly  comfortable  life,  the  com- 
pensatory hypertrophy  wears  out  and  is  replaced 
by  further  dilatation.  The  fatal  sequence  may  be 
summarised  thus  :  regurgitation,  dilatation,  weakened 
systole,  impaired  coronary  circulation,  further  dilata- 
tion and  increased  regurgitation.1 

Another   fatal   sequence   is   common  in    patients 
suffering    from    mitral    stenosis. 
Coombs  writes  : 

"  In  a  large  majority  of  all  cases  of  mitral  stenosis 
death  is  due  to  gradual  cardiac  failure.  The  forces 
responsible  for  this  are  two.  The  heart,  and  especially 
the  left  auricle,  is  asked  to  do  more  work  by  reason  of 
the  valvular  obstruction  ;  and  generally  increasing 
venous  stasis  undermines  the  nutrition  of  the  cardiac, 
and  particularly  the  auricular,  musculature.  An  un- 
conquerable Vicious  Circle  is  thus  established.  The 
results  are  pulmonary  engorgement,  auricular  break- 
down, and  ultimate  ventricular  failure."2 

Sudden  death  is  sometimes  due  to  thrombosis  or 
embolism  of  the  heart  or  large  vessels.  If  not 
immediately  fatal,  the  embolus  or  thrombus  may 
cause  eddies  and  obstruction  which  in  their  turn 
lead  to  rapid  and  extensive  clotting.  This  steadily 
adds  to  the  size  of  the  embolus  or  thrombus,  thereby 
increasing  the  obstruction.  The  greater  the  obstruc- 
tion the  larger  the  surface  on  which  the  blood  can 
coagulate,  and  the  more  rapidly  does  the  obstruction 
grow. 

1  According  to  Manson  the  reciprocal    influence  of  cardiac 

dilatation  and  weakness  accounts  for  death  in  many 
cases  of  beriberi.  "  Gradually  the  right  side  of  the 
heart  becomes  more  dilated,  and  in  proportion  to  the 
dilatation  more  weakened,  passing  into  one  of  those 
hopeless  Vicious  Circles  so  common  in  pathology." 
Davidson,  Hygiene  and  Diseases  of  Warm  Climates, 

P-  473 

2  Short,  Index  of  Prognosis,  p.  320, 


Circle  ae  a  Cause  of  2Deatb      271 

Pericardial  Effusion.  Interference  with  diastolic 
filling,  owing  to  pericarditis  or  to  rupture  of  an 
aneurysm,  is  frequently  fatal,  since  such  interference 
prevents  the  stretching  of  the  cardiac  muscle  which 
is  so  essential  to  the  full  development  of  its  energy. 
A  case  in  which  death  occurred  from  this  cause  is 
described  on  p.  52. 

Congenital  Heart  Disease.  Congenital  morbus 
cordis  is  not  an  uncommon  cause  of  death,  and  has 
been  already  alluded  to  in  Chapter  IV.  Some- 
times the  demise  may  be  due  to  an  open  foramen 
ovale.  This  malformation  is  usually  complicated 
with  pulmonary  stenosis  which  allows  enough  blood 
to  reach  the  lungs,  so  long  as  a  quiet  mode  of  life 
is  pursued,  while  the  remainder  of  the  blood  passes 
through  the  foramen  ovale.  If,  however,  violent 
exercise  is  taken,  more  blood  must  pass  through  the 
foramen  directly  to  the  left  side  of  the  heart  and 
thus  escapes  aeration.  The  result  of  the  venosity 
is  a  rise  in  blood-pressure,  which  again  causes  more 
blood  to  be  driven  through  the  foramen,  ending  at 
times  in  speedy  death. 

Rupture  of  Heart.  Spontaneous  rupture  of  the 
heart  may  be  due  to  progressive  degenerative 
changes  and  dilatation  of  the  cardiac  muscle  (jplatC 
XVI.  b).  As  the  strain  on  the  walls  of  a  sphere  or 
spheroid  increases  with  its  circumference,  so  the 
heart  dilates  the  more  the  greater  the  strain  on  its 
walls,  leading  to  further  dilatation  and  occasionally 
to  rupture.  When  rupture  has  occurred,  the  primary 
loss  of  blood  stimulates  the  vaso-motor  centre,  which 
stimulus  calls  forth  a  general  vaso-constriction, 
raises  the  blood-pressure,  and  thus  intensifies  the 
haemorrhage.  A  similar  sequence  may  be  associated 
with  rupture  of  an  aneurysm  or  a  penetrating  wound 
of  the  heart.  Probably  King  William  Rufus  died 
from  perforation  of  his  heart  by  Walter  Tyrel's 


272  IDicioue  Circles  in  ^Disease 


arrow,  which  "  per  medium  cordis  regem  sauciavit 
qui   subito   mortuus   corruit." 

II.     DEATHS  ASSOCIATED  WITH  THE 
RESPIRATORY    SYSTEM 

Asphyxia.  Asphyxia,  due  to  the  interruption 
of  respiration,  is  a  frequent  cause  of  death,  and 
may  occur  under  a  variety  of  conditions.1 

In  consequence  of  the  obstructed  respiratory 
exchange  the  venosity  of  the  blood  increases, 
respiratory  movements  grow  more  vigorous,  blood- 
pressure  rises,  and  the  heart  is  slowed  by  the  cardio- 
inhibitory  centres  in  the  medulla.  The  increased 
pulmonary  obstruction  then  causes  the  right  heart 
to  become  gorged  with  blood,  and  eventually  dilated 
and  weakened.  This  in  turn  leads  to  further  venosity 
which  poisons  the  myocardium  and  tends  to  further 
dilatation,  until  at  length  the  right  auricle  and 
ventricle  lose  all  power  of  contracting.  A  similar 
process  also  involves  the  left  side  ;  but  the  pro- 
gressive dilatation  of  the  right  side  plays  the  chief 
role,  and  contributes  mainly  to  the  fatal  exitus 

BMate  xvi.  c). 

Pulmonary  atelectasis  is  frequently  fatal  in  weakly 
or  rickety  infants,  whose  death  gives  rise  to  great 
consternation,  since  what  appeared  at  first  to  be 
a  trifling  catarrh  may  suffice  to  start  the  fatal 
sequence.  Any  accumulation  of  secretion  is  liable 
in  such  weaklings  to  diminish  the  quantity  of  air 
entering  the  air  cells,  and  such  diminution  favours 
a  further  accumulation.  The  associated  venosity 
of  the  blood  may,  through  interference  with  the 
normal  reflexes,  constitute  an  aggravating  factor. 

The  gradual  asphyxia  which  so  often  supervenes 
during  the  terminal  stage  of  illness  is  also  com- 

1  A  case  of  death  due  to  the  Vicious  Circle  associated  with 
goitre  and  tracheal  stenosis  was  published  by  the 
author  in  1887.  Lancet,  1887,  I.,  p.  570. 


ftbe  Circle  as  a  Cause  of  2)eatb      273 

plicated  by  a  circular  reaction.  The  shallow  respira- 
tions do  little  to  aerate  the  blood,  and  thus  induce 
narcosis  of  the  respiratory  centre,  still  shallower 
respirations  and  death.  This  is  indeed  a  merciful 
process  which  leads  to  a  peaceful  painless  end. 
Nature  often  provides  her  own  anaesthetic  for  us 
at  the  last. 

Asphyxia  neonatorum  is  often  complicated  by  a 
Vicious  Circle  and  may  result  from  any  condition 
which  leads  to  an  accumulation  of  CO2  in  the  blood 
of  the  foetus.  The  danger  arises  from  the  fact  that 
such  accumulation  may  prematurely  interrupt  the 
state  of  apnoea  which  should  persist  during  intra- 
uterine  life. 

If  CO2  accumulates  beyond  a  certain  point,  it 
stimulates  the  respiratory  centre  so  that  the  foetus 
makes  its  first  respiratory  effort  and  inspires  amniotic 
fluid  if  the  amniotic  sac  is  intact,  or  that  fluid  mixed 
with  blood  and  mucus  if  the  sac  has  burst.  Thus 
as  in  the  case  of  a  drowning  person  inspiration  does 
little  toward  oxygenation,  but  tends  rather  to  further 
accumulation  of  CO2.  Moreover  during  the  state 
of  apnoea  the  lungs  receive  but  little  blood,  since 
the  powerful  right  auricle  propels  the  greater  portion 
of  its  blood  through  the  ductus  Botalli  into  the 
aorta.  With  the  first  inspiratory  effort,  however, 
the  blood  in  the  right  auricle  is  aspirated  into  the 
pulmonary  artery  instead  of  passing  directly  into 
aorta.  The  result  is  that  the  blood-pressure  in  the 
aorta  falls  considerably,  leading  to  further  venosity. 
Unless  speedy  relief  is  forthcoming,  the  respiratory 
centre  is  paralysed  by  the  excess  of  CO2  and  death 
supervenes  from  what  Lenzmann  calls  "  a  very 
grave  Vicious  Circle . " l 

Asphyxia  may  also  prove  fatal  before  a  single 
respiration  has  taken  place  when  the  accumulation 


1  Emergencies  in  Medical  Practice,  p.  17. 


274  IDicious  Circles  in 


of  CO2  is  so  gradual  as  never  to  reach  the  limit  of 
stimulation.  In  such  cases  the  acid  increasingly 
narcotises  the  respiratory  centre  and  renders  it 
less  and  less  susceptible  to  stimulation  until  death 
takes  place.1 

Haemoptysis.  Haemoptysis  may  be  complicated 
by  dangerous  correlations  which  are  largely  respon- 
sible for  the  profusion  and  prolongation  of  the 
haemorrhage  (JMatC  XVI.  d).  In  the  first  place  the 
irritation  of  the  effused  blood  induces  cough  ; 
coughing,  like  any  other  exertion,  raises  blood- 
pressure  ;  increased  blood-pressure  is  apt  to  renew 
the  haemorrhage.  Thus  in  a  severe  attack  a  person 
may  be  choked  in  his  own  blood.  Mental  excite- 
ment supplies  an  aggravating  factor,  as  it  also 
does  in  the  allied  condition  of  haematemesis.  Such 
excitement  may  produce  a  rise  of  as  much  as  40  mm  . 
Hg  in  the  systolic  pressure.  Lastly,  we  may  have 
the  same  general  vaso-constriction  due  to  anaemia 
of  the  vaso-motor  centre  that  has  already  been 
alluded  to.  These  factors,  acting  cumulatively, 
adequately  explain  the  fatal  haemoptysis  that  is 
sometimes  met  with.  A  man  may  cough  himself 
into  his  grave. 

A  similar  mode  of  death  may  result  from  the 
perforation  of  an  empyema  into  the  respiratory 
passages.  Every  cough,  although  an  act  of  self- 
defence,  increases  the  flow  of  pus,  which  may  flood 
the  passages,  in  spite  of  vigorous  expectoration. 

Pick  and  Hecht  write  : 

"  The  more  the  patient  coughs,  the  more  profusely 
the  pus  streams  into  the  bronchi  as  a  result  of  the 
expiratory  rise  in  pressure,  and  such  a  circulus  vitiosus 
can  only  end  in  death."2 

1  Lenzmann,  Emergencies  in  Medical  Practice,  p.  18.    Cf  .  also 

Schultze,  Der  Scheintod  Neugeborener,  pp.  77-8,  in. 

2  Clinical  Symptomatology,  p.  259. 


ftbe  Circle  as  a  Cause  of  Death      275 

The  condition  is,  however,  by  no  means  so  hopeless 
as  Pick  and  Hecht  suggest. 

Other  fatal  disorders  associated  with  the  respir- 
atory tract  will  be  found  in  Chapters  V.  and  XII. 

III.     DEATHS    ASSOCIATED    WITH    THE 
NERVOUS   SYSTEM 

Apoplexy.  Cerebral  haemorrhage  may  prove 
fatal  through  the  intermediary  of  a  striking  circular 
reaction.  The  causal  factors  have  already  been 
described  (p.  29)  and  need  not  be  repeated.  Where 
death  supervenes  rapidly,  the  effused  blood  has 
probably  compressed  and  paralysed  the  vagal  and 
respiratory  centres  in  the  medulla.  Such  a  course 
of  events,  however,  is  uncommon  ;  the  fatal  issue 
is  more  often  due  to  another  sequence  in  which 
exhaustion  of  the  vaso-motor  centre  leads  to 
splanchnic  dilatation,  cerebral  and  cardiac  anaemia, 
further  exhaustion  and  death  (JMate  XVI.  e). 

Vase-motor  Paralysis.  Death  is  sometimes  due 
to  inhibition  or  paralysis  of  the  vaso-motor  centres 
as  a  result  of  terror  or  other  strong  emotion  (iDlate 
XVI.  f). 

During  health  the  activity  of  those  centres  is 
increased  or  diminished  according  as  arterial  press- 
ure falls  or  rises.  But  strong  emotion  ma}'  paralyse 
the  vaso-motor  mechanism  ;  the  splanchnic  sluice 
gates  are  opened,  the  blood-pressure  falls,  the 
cerebral  vessels  are  emptied,  with  the  result  that  the 
depression  of  the  centres  is  accentuated,  possibly 
beyond  recovery.  The  heart  too  may  be  involved  in 
the  injurious  process,  since,  owing  to  the  progressive 
accumulation  of  blood  in  the  splanchnic  area,  an 
insufficient  quantity  may  return  to  the  heart  to 
enable  the  circulation  to  be  carried  on .  The  defective 
coronary  circulation  still  further  weakens  the  myo- 
cardium, with  the  effect  that  the  heart  may  suddenly 
stop  in  diastole.  This  is  probably  the  mechanism 


276          IDicious  Circles  in  Disease 


of  death  in  various  forms  of  shock,  in  the  collapse 
often  met  with  during  acute  disease,1  in  severe 
diarrhoea,  in  perforation  of  abdominal  viscera  etc.2 

Convulsions.  Convulsions  are  not  infrequently  a 
cause  of  death,  owing  to  the  associated  increased 
venosity  of  the  blood  which  may  be  both  the  result 
of  preceding,  and  the  cause  of  subsequent,  convulsions. 
Such  a  sequence  is  commonly  observed  in  the  status 
epilepticus,  as  has  been  already  explained  on  p.  28. 

Hydrocephalus.  Death  is  occasionally  met  with 
in  cases  of  hydrocephalus,  when  the  fluid  has  accumu- 
lated in  the  ventricles  owing  to  a  mutuality  of  cause 
and  effect.  The  primary  lesion  may  be  some 
obstruction  in  the  communicating  channels,  leading 
to  dilatation  of  the  ventricles.  The  dilated  ventri- 
cles may  then  so  displace  the  adjacent  parts  as  to 
press  on,  and  increase,  the  obstruction  in  the  narrowed 
channel  to  which  the  accumulation  of  fluid  was 
primarily  due.  For  example,  the  cerebellum  and 
medulla  may  be  pressed  down  into  the  foramen  mag- 
num so  as  to  plug  that  aperture.  Such  plugging  in 
turn  increases  the  distension  of  the  ventricles,  raising 
the  pressure  to  such  a  level  that  the  respiratory 
centre  is  paralysed. 

These  illustrations  suffice  to  establish  the  pro- 
position that  the  fatal  issue  of  disease  is  frequently 
due  to  the  operation  of  an  injurious  reciprocation  of 
disorders. 

Similar  conditions  are  operative  in  many  forms  of 
violent  death,  e.g.  drowning,  hanging,  cut-throat  and 
poisoning. 

*A  50  p.c.  mortality  in  attacks  of  influenzal  broncho- 
pneumonia  is  attributed  by  Symonds  to  the  Vicious 
Circle  of  toxaemia  and  nephritis.  Lancet,  igi8,  II.,  p. 665. 

2Heineke,  Die  Todesursache  bei  Perforationsperitonitis, 
Deutsches  Archiv  f.  klin.  Medicin  (1901) , LXIX., p.  429. 


Chapter  Eighteen 


ARTIFICIAL   CIRCLES 

ANY  injurious  circular  reactions  are  associ- 
ated with  the  natural  processes  of 
pathology.  Others  are  dependent  on 
injudicious  therapeutics  or  social  customs. 
These  may  be  termed  Artificial  Circles — 
circuli  factitii,  and  various  examples  have  already 
been  described  in  the  preceding  pages.  Their  impor- 
tance, however,  justifies  a  separate  Chapter,  which 
may  serve  to  warn  the  profession  of  the  evil  effects 
that  often  result  from  ill-considered  treatment. 

Cathartics.  The  excessive  use  of  cathartics,  due 
to  the  blatant  advertisement  of  the  quack  or  to  the 
impatience  of  over-zealous  disciples  of  ^sculapius, 
is  responsible  for  a  highly  pernicious  sequence  of 
events. 

Like  all  other  physiological  processes,  faecal  evacu- 
ations vary  in  frequency  and  in  quantity  within  the 
limits  of  health.  Over-stimulation  on  one  day  is 
followed  by  a  period  of  diminished  activity  the 
next  day  and  vice  versa.  By  this  self -regulating 
process  Nature  ensures  a  sufficiency  of  intestinal 
relief. 

Unfortunately  many  persons  attach  undue  impor- 
tance to  trivial  deviations  from  normal  defsecation 
and,  forgetful  of  Nature's  powers  of  adjustment, 
fly  to  cathartics  whenever  there  has  been  a  deficient 
relief.  The  result  is  an  over-stimulation  of  the 

277 


278  IDicioue  Circles  in  Disease 

bowels  followed  by  an  aggravated  constipation, 
which  is  then  attacked  by  larger  doses  of  aperient. 
So  the  process  continues,  resulting  in  intestinal 
catarrh  and  atony,  and  provoking  more  and  more 
obstinate  coprostasis  ((Mate  XV11.  a). 

Sir  Henry  Holland  many  years  ago  called  attention 
to  this  sequence  of  events  : 

"  The  habitual  irritation  of  the  mucous  membrane 
by  cathartics  alters  and  depraves  its  secretions  through- 
out the  whole  course  of  the  alimentary  canal,  becoming 
thereby  a  further  source  of  mischief  and  suffering 
to  the  patient.  These  disordered  secretions  are  too 
often  urged  in  proof  of  the  need  of  further  evacuation. 
And  thus  the  practice  proceeds  in  a  Vicious  Circle  of 
habit  from  which  the  patient  is  rarely  extricated  with- 
out more  or  less  injury  to  his  future  health."1 

Wilkinson  has  thus  described  the  injurious  effects 
of  excessive  purgation  : 

"  The  use  of  drugs  requires  clinical  acumen,  common 
sense  and  shrewd  observation,  lest  the  drugs  make 
matters  worse  by  establishing  a  still  greater  inhibition 
of  the  ordinary  processes,  digestive,  muscular  and 
nervous,  upon  which  the  regular  and  complete  evacua- 
tion of  the  bowel  depends.  Such  want  of  skill  and  care 
may  establish  a  Vicious  Circle  at  one  segment  of  which 
such  severe  and  distressing  conditions  as  membranous 
colitis,  chronic  catarrh  and  even  visceral  neurasthenia 
may  obtrude  themselves."2 

Morphia.  Another  important  artefact  is  associ- 
ated with  the  habitual  use  of  morphia  and  other 
narcotics  (jMate  XVII.  b)  ;  the  habitue  becomes  en- 
snared within  the  coils  of  a  habit  from  which 
escape  is  all  but  hopeless.  The  drug,  while  satiating 

1 "  On  the  Abuse  of  Purgative  Medicines."  Medical  Notes 
and  Reflections,  1839,  P-  IO°-  This  is  the  earliest 
reference  to  the  expression  "  Vicious  Circle  "  which 
I  have  met  with  in  a  medical  work. 

2  Practitioner ,  1910,  II.,  p.  638. 


artificial  Circles 


279 


Recot 


i)  ABUSE  OF  CATHARTICS 


(b)  ABUSE  OF  MORPHIA 


(c)  ABUSE  OF  ALCOHOL  (d)  ABUSE  OF  STRYCHNINE 


(e)  ABUSE  OF  VENESECTION         (f)  ABUSE  OF  RESTRAINT 


plate  XVII.— artificial  Circles. 


280          iDlcioug  Circles  in  IDigcase 

the  immediate  craving,  creates  an  appetite  for 
further  indulgence,  and  weakens  that  self-control 
without  which  no  salvation  is  possible.  As  Virgil 
says:  cegrescit  medendo,  "  the  disorder  increases  with 
the  remedy." 

Tourette  writes  : 

"  This  condition  gives  rise  to  a  true  Vicious  Circle. 
.  .  .  The  morphinomaniac  flies  to  his  syringe  before 
meals  in  order  to  awaken  an  appetite  which  is  always 
indifferent.  After  meals  the  injection  is  repeated  in 
order  to  assist  digestion.  ...  As  time  goes  on,  the 
drug  is  used  more  and  more  often  and  in  larger  and 
larger  quantities."1 

Tanzi  also   describes  the  condition  : 

"  Each  new  injection  must  be  larger  or  more  quickly 
repeated  than  the  preceding  one,  in  order  to  give  the 
desired  effect.  Thus  a  Vicious  Circle  is  established, 
which  gives  morphinism  the  character  of  a  fatally 
progressive  habit."2 

Morphia  has  frequently  been  used  in  attacks  of 
cardiac  dyspnoea,  with  results  which  in  the  long  run 
have  proved  highly  injurious.  The  drug  temporarily 
relieves  distress,  but  at  the  same  time  diminishes  the 
irritability  of  the  respiratory  centre  and  thus  allows 

1  Maladies     du     Systeme     Nerveux,     p.     244.       Cf.     also 

Curschmann,   L,ehrbuch  der  Nervenkrankheiten,  p. 

903- 

2  Text-Book  of  Mental  Diseases,  p.  334.     Cf.   also  British 

Med.  /.,  1911,  I.,  Epitome,  p.  32  ;  Haydn  Brown, 
Advanced  Suggestion,  p.  191.  Brown  substitutes 
the  expressions  "  positive  or  favourable "  and 
"  negative  circlings "  for  "  virtuous  or  vicious 
circles."  In  another  Volume  "  The  Secret  of  Human 
Power"  the  operation  of  Vicious  Circles  is  discussed. 
Thus  on  p.  73  he  writes  :  "In  future  no  organic 
or  functional  disorder  can  be  adequately  studied 
without  regard  for  negative  and  positive  circling  ; 
such  is  the  importance  of  the  subject." 


Hrtifidal  Circles  281 

more  CO2  to  accumulate  in  the  blood.  The  patient 
then  requires  an  increasing  dose  of  morphia  in  order 
to  obtain  relief,  and  a  dangerous  condition  is  created 
which  Hirschf elder  represents  in  the  following  way  :* 

Accumulation  of  CO  2  Paroxysm  of 

in  the  lungs  acapnia 

Diminished  irritability     < — «*    Morphine 
of  respiratory  centre 

In  some  cases  the  patient  is  so  addicted  to 
morphia  that  he  brings  on  a  paroxysm  of  dyspnoea 
voluntarily,  and  of  course  does  himself  great  harm 
by  so  doing. 

Similar  correlations  may  be  established  by  cocaine 
and  other  drugs  whose  use  leads  to  repetition,  to 
habituation  and  finally  to  volitional  palsy.  Cocaine 
may  impose  an  even  worse  slavery  than  does 
morphia. 

Alcohol.  The  habitual  indulgence  in  alcohol 
frequently  ends  in  the  establishment  of  a  Vicious 
Circle,  which  possesses  great  interest  both  for  the 
physician  and  the  sociologist.  Indeed  it  is  owing 
to  this  complication  that  alcoholism  exacts  such  a 
heavy  toll  in  disease,  in  poverty,  in  crime  and  in 
death.2 

There  are  many  reasons  for  the  prevalent  addiction 
to  alcoholic  indulgence.  Amongst  the  commonest 
are  its  power  of  creating  a  sense  of  bodily  and 
mental  comfort,  and  of  promoting  a  temporary 
oblivion  of  misery  and  poverty.  As  we  read  in 


Diseases  of  the  Heart  and  Aorta,  p.  205. 

2Cf.  Chronic  Alcoholism  and  its  Vicious  Circles,  by  J.B.H., 
British  ] .  of  Inebriety,  1915,  II.,  p.  13.  Cf.  also 
Poverty  and  its  Vicious  Circles,  by  J.B.H.,  p.  56. 


282 IPidoue  Circles  in  2>tsea0e 

the  Book  of  Proverbs  "  Give  wine  unto  the  bitter 
in  soul  ;  let  him  drink  and  forget  his  poverty,  and 
remember  his  misery  no  more." 

Moreover  alcoholic  indulgence  is  particularly 
seductive  and  dangerous,  since  it  does  not  evoke 
that  sense  of  satiety  which  generally  attends  excess. 
On  the  contrary,  over-indulgence  induces  a  craving 
for  more  ;  Nature  gives  no  signal  when  to  stop 
Iplfltc  XVII.  c).  Self-control  is  therefore  required 
in  order  to  keep  consumption  within  judicious  bounds 
and  that  self-control  is  often  lacking.  Any  primary 
weakness  of  volition  is  further  increased  by  its 
results,  so  that  the  evil  is  steadily  re-inforced. 

Stocker  writes  : 

"  Chronic  alcoholism  always  plays  a  very  pernicious 
role,  since  it  leads  to  the  establishment  of  a  Vicious 
Circle.  The  injury  to  the  brain  caused  by  excessive 
use  of  alcohol  provokes  a  further  desire  to  drink  and 
diminishes  the  power  of  resistance  to  the  injurious 
effects  of  alcohol."1 

While  every  person  who  indulges  regularly  in 
intoxicant  liquors  is  liable  in  course  of  time  to  the 
evil  effects  of  habituation,  neuropathic  individuals 
run  the  greatest  danger,  owing  to  their  greater 
nervous  instability. 

McBride  writes  : 

"  The  instability  of  the  nerve  force  in  neurasthenic 
individuals  induces  the  taking  of  alcohol,  which  in  turn 
increases  the  instability,  this  leading  to  excessive  use 
of  the  stimulant  ;  and  thus  the  Vicious  Circle  goes  on, 
to  the  complete  undoing  of  the  victim."2 

Apart  from  the  mental  effects  of  chronic  alcohol- 
ism, there  are  often  local  disorders  which  also  tend 
to  self -perpetuation.  One  of  them  is  dilatation  of 

1  Beitrag  zur  Frage  der  Alcoholpsychosen,  p.  296. 

2  The  Modern  Treatment  of  Alcoholism  and  Drug  Narcotism, 

p.  78. 


artificial  Circles  283 

the  stomach  associated  with  impaired  peristaltic 
activity.  This  condition  provokes  a  sense  of  ex- 
haustion and  disinclination  for  work,  which  tempts 
to  further  indulgence.  The  dilatation  and  stasis 
also  tend  to  flatulence,  which  aggravates  the  dilata- 
tion. 

Horsley  and  Sturge  write  : 

"  In  this  condition  the  stomach  never  contracts 
fully  and  effectively  so  as  to  expel  its  contents  into  the 
bowel  ;  hence  it  always  contains  some  remnants  of  a 
meal,  which  ferment  and  cause  '  wind.'  This  in  its 
turn  tends  to  inflate  the  stomach  and  itself  to  increase 
the  dilatation,  and  thus  the  Vicious  Circle  goes  on."1 

If  the  misguided  victim  still  flies  to  the  bottle 
for  relief,  he  but  pursues  a  will-o'-the-wisp  that  lures 
to  destruction. 

Bromides.  The  incautious  use  of  bromides  has 
done  great  harm.  Few  drugs  have  a  stronger 
tendency  to  lower  the  recuperative  power  of  a 
disordered  nervous  system.  Yet,  especially  in  former 
days,  bromides  have  been  extensively  administered 
to  benefit  the  very  conditions  in  which  that  recuper- 
ative power  was  lacking. 

Traumatic  neurasthenia,  such  as  is  sometimes 
caused  by  a  railway  accident,  may  serve  as  an  illus- 
tration. Such  accidents  are  frequently  followed  by 
spinal  tenderness,  stiffness  and  pain,  associated  with 
nervous  prostration.  These  symptoms  were  form- 
erly attributed  to  irritation  or  inflammation  of  the 
spinal  cord,  which  must  be  arrested  by  sedatives, 
and  led  to  the  administration  of  large  doses  of 
bromide  of  potassium  for  weeks  together.  Unfortun- 
ately bromide  may  produce  symptoms  closely  akin 
to  those  of  traumatic  neurasthenia,  with  the  result 
that  unwary  practitioners  often  confused  the  effects 

1  Alcohol  and  the  Human  Body,  pp.  193,  205. 


284          IDicious  Circles  in  Disease 


of  the  bromide  with  those  of  the  injury  and  continued 
to  increase  the  dose.  No  wonder  that  the  symptoms 
steadily  grew  worse.  Cause  and  effect  were  inex- 
tricably confused,  further  bromide  of  potassium 
being  administered  to  remove  the  very  disorder 
the  drug  had  produced. 

A  case  of  litigation  is  actually  on  record  in  which 
a  claim  was  based  on  the  presence  of  inflammation  of 
the  cord  and  its  membranes  as  proved  by  a  cutaneous 
eruption,  which  eruption  was  in  reality  an  acne 
induced  by  bromide  of  potassium  !  l 

Strychnine.  Strychnine  is  another  drug  which 
has  often  been  incautiously  used,  e.g.  in  cases  of  post- 
operative shock,  associated  with  exhaustion  of  the 
vaso-motor  centres  and  fall  of  blood-pressure.  Recent 
research,  however,  proves  that  stimulants  are  useless 
for  the  purpose  of  arresting  such  a  fall.  In  fact 
their  administration  both  weakens  vaso-motor  action 
and  lowers  pressure,  being  tantamount  to  flogging 
a  tired  horse  (plate  XVII.  d).  In  other  words, 
the  presence  of  shock  led  to  the  administration  of 
strychnine,  the  very  drug  best  calculated  to  increase 
shock.2 

Iodides.  A  grievous  artefact  has  at  times  been 
established  when  potassium  iodide  has  been  pre- 
scribed for  the  cure  of  various  forms  of  dermatitis, 
and  has  then  provoked  an  iododerma  which  is 
attributed  to  the  original  disorder.  Increased  doses 
of  iodide  may  be  then  ordered  in  ignorance  of  the 
real  cause  of  the  aggravation,  and  in  the  hope  of 
curing  the  very  lesions  the  drug  has  produced  ! 


1  Medical  Times,  1885,  I.,  p.  437. 

2  Cook  and  Briggs,  John  Hopkins  Hospital  Reports,  1903, 

p.  470.     Cf.  also  Crile  and  Lower,  Anoci-Association, 
p.  20. 


artificial  Circles  285 


There  can  be  no  doubt  that  death  has  sometimes 
resulted  from  such  a  lamentable  error. 

Thibierge  writes  : 

"  The  various  lesions  provoked  by  iodide  of  potassium 
are  often  mistaken  for  manifestations  of  syphilis.  This 
error  of  diagnosis  leads  to  further  use  of  the  remedy,  or 
even  to  increased  doses.  Hence  result  a  persistence 
and  aggravation  of  the  eruption."1 

Brocq,   speaking  of  iodide  eruptions,  says  : 

"  When  the  true  nature  of  the  eruption  is  not  recog- 
nized, and  the  physician  consequently  persists  in  the 
administration  of  the  iodide,  the  cutaneous  lesions 
rapidly  increase  in  number  and  severity,  invade  the 
mucous  membranes,  and  become  haemorrhagic.  Album- 
inuria,  diarrhoea  and  marasmus  gradually  supervene, 
and  the  patient  may  succumb."2 

The  danger  is  perhaps  all  the  greater  from  the 
fact  that  there  seems  to  be  no  such  thing  as  accou- 
tumance  to  iodides.  One  attack  of  a  drug  eruption 
seems  to  intensify  the  susceptibility  to  subsequent 
attacks.3 

Sulphur.  The  prolonged  use  of  sulphur  in  the 
treatment  of  scabies  occasionally  excites  a  dermatitis 
that  may  be  mistaken  for  the  original  disease  and 
is  therefore  continued  more  vigorously  than  before, 
with  annoying  consequences.  Indeed  such  a  der- 
matitis may  be  kept  up  for  many  months,  long 
after  all  the  acari  have  been  destroyed.4  Some- 
times the  error  is  due  to  ignorance.  In  other  cases 
neurotic  auto-suggestions  lead  to  this  prolonged 
treatment. 


1  Pratique  Dermatologique,  II.,  p.  487. 

2  Dermatologie  Pratique,  I.,  p.  412. 

3  Morrow,  Monographs  on  Dermatology,  1893,  pp.  367,  500. 
4Hartzell,  Diseases  of  the  Skin,  p.  449. 


286          iDtctoug  Circles  in  Disease 

Dubreuilh  writes  : 

"  There  are  some  persons  who  have  recovered  from 
scabies,  but  who,  in  consequence  of  the  attack  and  of 
the  treatment  adopted,  are  still  suffering  from  a  more  or 
less  extensive  eczema.  They  will  not  believe  them- 
selves cured,  and  worry  their  doctor  to  order  them 
more  and  more  active  treatment.  This  only  aggravates 
the  eruption  and  the  itching,  so  that  the  poor  sufferer 
cannot  escape  from  the  Vicious  Circle  in  which  he  is 
caught."1 

Anaesthetics.  Dangerous  correlations  may  occur 
during  the  administration  of  chloroform,  especially 
if  the  vapour  is  administered  in  too  concentrated  a 
form.  The  danger  depends  on  the  anatomical 
arrangement  in  virtue  of  which  the  heart  receives 
the  blood  containing  the  largest  quantity  of  the 
anaesthetic,  which  only  reaches  other  portions  of 
the  body  after  passing  through  the  heart. 

Meyer  and  Gottlieb  write  : 

"  The  heart  can  be  very  seriously  poisoned  by  the 
sudden  entrance  into  it  of  blood  containing  too  much 
chloroform,  even  before  any  general  narcosis  has 
developed.  If  by  such  abrupt  administration  of 
chloroform  the  action  of  the  left  ventricle  is  markedly 
weakened  for  even  a  short  time,  a  Vicious  Circle  is 
produced,  which  with  each  instant  augments  the  damage 
suffered  by  the  heart.  For,  as  the  heart  empties 
itself  but  incompletely,  it  is  directly  exposed  to  a 
persisting  poisonous  action  of  the  blood  stagnating 
in  it  and  containing  poisonous  amounts  of  chloroform, 
and  consequently  results  in  death  of  the  heart."2 

Another  injurious  sequence  often  complicates 
the  administration  of  anaesthetics  when  there  is 
persistent  reflex  rigidity,  since  such  rigidity  may  be 
accompanied  by  spasmodic  closure  of  the  larynx 

1  Pratique  Dermatologique,  II.,  p.  739. 

2  Pharmacology,  p.  64. 


artificial  Ctrclee 287 

and  retraction  of  the  tongue.  The  resulting  non- 
aeration  of  the  blood  may  in  its  turn  aggravate 
rigidity,  and  give  rise  to  a  dangerous  complication 
which  must  be  dealt  with  by  inducing  a  deeper 
anaesthesia .  This  process  of  reciprocation  has  already 
been  referred  to  on  p.  206. 

Artefacts  are  by  no  means  confined  to  drugs  ; 
many  illustrations  are  connected  with  surgery  and 
surgical  appliances. 

Venesection.  Perhaps  the  most  tragic  example 
may  be  found  in  the  use  of  venesection  as  practised 
for  many  centuries.  Formerly,  indeed,  venesection 
was  regarded  as  a  panacea  for  almost  every  ailment, 
acute  or  chronic,  and  the  evidence  is  only  too  clear 
that  venesectio  ad  mortem  was  no  uncommon  occur- 
rence, death  being  erroneously  attributed  to  the 
illness  instead  of  to  the  loss  of  blood. 

The  custom  was  to  bleed  until  the  patient  became 
faint,  when  recovery  was  allowed  to  take  place.  In 
the  case  of  some  diseases,  such  as  pneumonia, 
peritonitis  and  typhoid,  where  there  is  fever  or  pain, 
some  remission  of  the  symptoms  followed  recovery 
from  the  faintness,  a  remission  which  was  hailed 
as  evidence  of  the  beneficence  of  the  operation, 
and  led  to  its  being  repeated  again  and  again,  if 
fever  or  pain  recurred. 

When,  however,  blood  is  drawn  pleno  rivo,  the 
symptoms  produced  (palpitation,  vertigo,  violent 
headache,  jactitation,  convulsions,  coma)  are  apt  to 
resemble  those  of  inflammatory  disorders,  and  are 
then  liable  to  be  imputed  to  a  recrudescence  of  the 
original  mischief,  although  really  due  to  anaemia. 
Unwary  practitioners  confused  cause  and  effect, 
venesection  being  repeated  to  remove  the  very 
symptoms  it  had  produced  (plate  XVII.  e).  In 
fact  the  more  marked  the  effects  caused  by  the  loss 
of  blood,  the  more  freely  was  blood  drawn.  Vene- 


288          iDidous  Circles  in  Disease 

section  was  carried  to  such  excess  as  to  kill  many 

patients  who  would  have  recovered  perfectly  if  they 

had  been  left  alone. 

The  Lancet  of    1827  records  an  illustrative  case 

which   may  be  briefly  summarized  : 

A  man  fell  from  a  scaffold  and  fractured  several  ribs. 
On  reaching  St.  Bartholomew's  Hospital  early  on  a 
Friday  morning  he  was  bled  18  oz.,  and  at  noon  20  oz. 
more.  The  next  day  a  further  18  oz.  were  taken,  and 
on  the  following  day  18  oz.  at  noon  and  18  oz.  in  the 
evening.  On  Monday  the  pulse  was  small  and  jerking, 
but  very  compressible.  This  condition  was  regarded 
as  "  indicative  of  inflammation  and  not  resulting  from 
loss  of  blood  or  hsemorrhagic  irritation."  Accordingly 
bleeding  was  again  ordered  to  the  extent  of  18  oz.  The 
dresser  in  charge  of  the  case,  however,  alarmed  by  the 
condition  following  the  loss  of  a  few  ounces,  desisted 
from  drawing  any  more.  Nevertheless,  when  about 
two  hours  later  two  surgeons  saw  the  man  in  consulta- 
tion, they  ordered  20  oz.  more  to  be  drawn.  After 
this  the  pulse  became  a  mere  flutter,  death  taking  place 
a  few  hours  later.1 

Irrigation.  Even  so  simple  an  operation  as 
irrigation  may  be  the  means  of  perpetuating  the  evil 
it  is  intended  to  cure.  Thus  in  cases  of  gonorrhoea 
the  careless  use  of  the  syringe  may  carry  infection 
from  the  anterior  into  the  posterior  urethra  and  even 
into  the  bladder.  Gonococci  implant  themselves  in 
what  has  hitherto  been  virgin  soil  and  frequently 
excite  posterior  urethritis,  epididymitis  and  cystitis. 
The  syringe  may  prove  a  curse  rather  than  a  blessing. 

Even  vaginal  irrigations  may  be  followed  by 
injurious  results.  They  are  frequently  ordered  for 
a  slight  increase  of  the  "whites,"  which  are  as  normal 


1  Lancet,  1827,  II.,  p.  94.  Cf.  also  Copland,  Dictionary 
of  Practical  Medicine,  I.,  p.  177  ;  Hale  White,  Text- 
Book  of  Pharmacology  and  Therapeutics,  p.  915. 


artificial  Circles  289 


for  some  women  as  is  a  slightly  increased  nasal 
discharge  in  others.  Such  slight  leucorrhcea  gener- 
ally cures  itself,  if  left  alone. 

The  habit  of  douching,  however,  washes  away 
the  normal  and  sterile  acid  secretions,  destroys  the 
superficial  Ia3'ers  of  cells  and  irritates  the  subjacent 
layers.  Local  hypersemia  is  thus  stimulated,  the 
quantity  of  secretion  is  increased,  and  even  menor- 
rhagia  may  be  provoked.  When  these  have  super- 
vened intensified  douching  is  prescribed,  cause  and 
effect  abetting  one  another.1 

Mechanical  Support.  Injudicious  treatment  is 
sometimes  associated  with  mechanical  supports, 
whose  primary  effect  may  be  beneficial,  while  the 
ultimate  result  is  to  increase  the  disability.  For 
example,  in  many  cases  of  spinal  weakness,  mechani- 
cal support  by  the  spinal  jacket  is  relied  upon  for 
the  cure  of  the  muscular  weakness.  The  support 
increases  the  spinal  weakness,  which  by  degrees 
requires  more  and  more  support.  Applying  the 
lesson  to  a  much  commoner  article  of  attire,  we 
may  say  that  the  corset  creates  the  demand  which 
it  supplies. 

The  same  principle  applies  to  the  use  of  irons 
for  weak-boned  children,  a  plan  which  violates 
the  principles  of  all  sound  practice.  Unless  such 
treatment  is  applied  with  great  circumspection, 
more  harm  than  good  may  result. 

Restraint  in  Insanity.  Another  illustration  is 
supplied  by  the  general  use  in  earlier  days  of  fetters, 
hand-cuffs,  strait  waistcoats  and  other  brutal  appar- 
atus for  the  coercion  of  the  imbecile  or  the  insane. 
Such  restraint,  in  lieu  of  promoting  amelioration, 
provoked  intense  resentment  and  excitement  or  even 

^othergill,  British  Med.  J.,  1918,  I.,  p.  445. 


290          IDicious  Circles  in 


permanent  mania,  the  secondary  irritation  being 
urged  as  a  plea  for  further  coercion  (JMatC  XVII.  f). 
Frequently  a  temporarily  excited  or  eccentric  person 
was  goaded  into  a  condition  of  permanent  lunacy  by 
the  treatment  that  was  inflicted.1 

These  atrocious  methods,  not  so  long  ago  univer- 
sally advocated  by  the  profession,  should  keep  us 
chastened  in  spirit,  and  serve  as  warnings  lest  a 
nimia  diligentia  lead  to  methods  of  treatment  of 
which  it  may  be  said  : 

plus  a  medico  quam  a  morbo  periculi. 


1  Gardiner  Hill,  Non-Restraint  System  of  Treatment  in 
Lunacy,  pp.  103  f.  Cf.  also  Griesinger,  Mental  Di- 
seases, pp.  491  f  ;  British  Med.  /.,  1910,  I.,  p.  519. 


Chapter  Bineteen 


THE   BREAKING   OF   VICIOUS   CIRCLES   BY 
NATURE 

N  first  thoughts  such  a  self-perpetuating 
process  as  a  Vicious  Circle  might  be  sup- 
posed incurable.  Indeed  the  supposition 
would,  in  many  cases,  be  justified,  as  is 
shewn  by  the  epithets  "  endless,"  "  eter- 
nal," "fatal,"  "lifelong,"  "hopeless,"  "infernal," 
"  unconquerable"  which  have  been  applied  to  this 
process. 

The  conclusion  that  no  Circle  can  be  broken  would, 
however,  be  a  serious  error.  Nature  frequently 
succeeds  in  interrupting  in j  urious  reciprocations .  By 
what  mechanism  is  such  a  result  obtained  ? 

In  the  Chapter  on  .^Etiology  it  was  pointed  out  that 
pernicious  circular  reactions  are  largely  the  result  of 
the  inter-dependences  of  organs.  When  the  power 
of  giving  vicarious  assistance  to  a  diseased  organ  is 
unduly  taxed,  the  second  organ  or  series  of  organs 
fails  to  meet  the  extra  demands  made  upon  it  and 
succumbs.  Such  failure  then  reacts  injuriously  on 
the  first,  and  so  the  process  continues. 

The  ability  to  render  vicarious  assistance  varies 
greatly,  being  dependent  on  age,  nutrition,  environ- 
ment and  other  factors.  Hence  there  is  an  infinite 
variety  in  the  processes  of  reciprocation  called 
forth,  when  injurious  reactions  have  been  initiated. 

The  problem  may  also  be  stated  thus  :  In  the 
sum-total  of  reactions  provoked  by  a  primary 

291 


292        tDicious  Circles  in  SMseaee 


disorder,  some  are  beneficent  and  some  are  male- 
ficent. If  the  beneficent  reactions  are  dominant 
the  disorder  takes  a  favourable  course  ;  the  opposite 
result  ensues  if  the  maleficent  reactions  prevail. 
This  predominance  -of  certain  reactions  over  others 
then  determines  the  issue,  whether  in  perpetuation, 
aggravation  or  recovery.1 

Where  the  factors  that  constitute  the  Vicious 
Circle  are  isodynamic,  recovery  is  impossible.  If, 
for  example,  in  severe  pneumonia  and  secondary 
cardiac  failure  there  is  an  equilibration  of  patho- 
logical factors  no  balance  of  recuperative  forces  is 
left.  Again  if  in  the  case  of  pulmonary  haemorrhage, 
the  cough  (factor  A)  expels  an  ounce  of  blood  from 
the  respiratory  passages,  while  the  concurrent  in- 
crease of  blood-pressure  (factor  B)  causes  another 
ounce  to  escape  from  the  bleeding  vessel,  the  morbid 
process  will  continue  until  death  results  from  anaemia . 
Or  if  in  pruriginous  disease  the  secondary  scratching 
causes  as  much  fresh  eruption  and  irritation  as  the 
vis  medicatrix  cures,  we  have  what  Kaposi  calls  an 
' '  endless  circulus  vitiosus. "  Again  if  chlorosis  causes 
as  much  blood  to  be  lost  by  epistaxis  or  menorrhagia 
as  can  be  manufactured  by  the  haemopoietic  organs, 
no  progress  is  possible.  In  Trousseau's  words, 
"  we  shall  always  be  turning  round  in  the  same 
Vicious  Circle."2  Since,  however,  the  beneficent 
reactions  are  as  a  rule  predominant,  recovery  is  the 
rule  ;  Nature  triumphs. 

The  methods  employed  by  Nature  vary  greatly. 
Some  of  them  aim  at  strengthening  one  organ  in 
rendering  vicarious  assistance  to  another  by  such 
simple  processes  as  enforced  rest,  hypertrophy, 
dilatation  and  so  forth.  In  many  other  cases, 
however,  an  extra-ordinary  mechanism  is  called 

1Allbutt,  Clinical  /.,  III.,  p.   194. 
-  Clinical  Medicine,  V.,  p.  109. 


a  be  Breahino  of  Circles  b£  mature  293 


(a)  MYOPIA 


(b)  VARICOSE  VEINS 


oz 


(c)  AORTIC  REGURGITATION 


/ 

(d)  QASTRECTASIS 


(e)  CARDIAC  FAILURE 


(f)  CHOLELITHIASIS 


plate  xvni  —  ITbe  »rcahinfi  of  tbe  Circle 
b\>  IRature. 


294          lDiciou9  Circles  (n  2)igcase 

into  operation  ;    this  is  what  Parkes  Weber  calls 
the    "  explosive   method."1 

Rest.  The  enforcement  of  rest  is  an  important 
method  by  which  injurious  circular  reactions  are 
interrupted.  Thus  progressive  myopia  may  be  at- 
tended by  such  severe  asthenopia  that  all  work 
involving  accommodation  must  be  abandoned.  The 
strain  on  the  ocular  muscles  during  convergence  and 
accommodation  is  thus  relieved  ;  the  pressure 
on  the  eye-ball  is  lessened  ;  the  progressive  posterior 
staphyloma  is  arrested  ;  the  incessant  demands 
on  the  visual  centres  are  lightened.  Reserves  of 
nervous  energy  can  be  accumulated,  and  after  an 
adequate  period  of  recuperation  the  self-aggravating 
factors  of  progressive  myopia  are  brought  to  an  end. 
((plate  XVII 1.  a).  The  abandonment  of  binocular 
vision  and  the  establishment  of  an  external  squint 
are  other  means  of  securing  rest  and  avoiding  the 
necessity  for  convergence. 

The  morbid  correlations  associated  with  inflamed 
varicose  veins  may  be  interrupted  in  a  similar  may. 
Enforced  recumbency  relieves  the  reciprocally  acting 
tension  and  dilatation  which  rendered  the  disorder  a 
steadily  progressive  one.  The  congestion  and  tension 
are  relieved.  In  other  cases  spontaneous  clotting 
may  completely  arrest  the  morbid  process  (IplatC 
XVIII.  b). 

Another  common  sequence  is  associated  with 
congestion  and  prolapse  of  a  subinvoluted  uterus, 
causing  continuous  back-ache,  whenever  the  woman 
is  on  her  feet.  Prolonged  rest  in  bed  or  on  the  sofa 
allows  the  displaced  and  engorged  organ  gradually 
to  return  to  its  normal  situation,  congestion  and 
prolapse  being  simultaneously  relieved. 


Vicious  Circles  in  Disease  and  Nature's   Efforts  to  deal 
with  them.     Practitioner,  1916,  II.,  p.  145. 


Breaking  of  Circlee  by  IRature    295 

Rest  is  also  the  usual  mechanism  by  which  dyspep- 
tic disorders  are  cured.  Here  the  functions  of  peristal- 
sis, secretion  and  absorption  are  simultaneously 
impaired,  depreciating  each  other  and  constituting 
"  a  Vicious  Circle  in  optima  forma."  Nature  imposes 
physiological  rest  by  the  suppression  of  appetite, 
and  the  production  of  nausea  or  pain.  Time  is  thus 
allowed  for  the  complete  digestion  of  remnants  of 
food,  for  the  removal  of  disordered  secretions  and  for 
the  building  up  of  reserves  of  enzymes  and  further 
aids  to  digestion.  In  other  cases  increased 
peristalsis  transfers  the  ingesta  into  the  bowel 
before  they  are  able  to  do  more  mischief.1  At  the 
same  time  Nature  often  awakens  a  desire  for  extra 
exercise,  such  as  a  gallop,  a  stiff  walk  or  out-door 
game,  thus  hastening  recovery  both  by  stimulating 
the  portal  circulation,  promoting  peristalsis  and 
evacuating  the  products  of  imperfect  digestion. 

Sleep  is  another  of  Nature's  methods  of  arresting 
circular  reactions,  especially  in  neurotic  disorders 
which  are  complicated  by  insomnia.  The  obstinate 
correlations  may  continue  in  operation  until  the 
neuron  threshold  is  greatly  depressed  and  the 
victim  a  complete  mental  and  physical  wreck.  All 
at  once,  as  if  by  the  wand  of  a  magician,  "  tired 
Nature's  sweet  restorer — balmy  sleep  "  breaks  the 
Circle.2 

Hypertrophy.  Hypertrophy  of  the  heart  is  an 
admirable  example  of  Nature's  method  of  arresting 
processes  of  reciprocation  in  many  cases  of  valvular 


!Ewald,  Diseases   of    the    Digestive   Organs,    II.,    p.    485. 

2  There  are  many  other  ways  in  which  neurotic  Circles 
may  be  broken.  Dr.  Claye  Shaw  tells  of  a  lady 
who  was  cured  of  insomnia,  depression  and  headache 
by  the  very  natural  process  of  having  a  baby. 
Lancet,  1911,  I.,  p.  357- 


296          IDidoue  Circles  in  HHeease 

disease.  For  example,  in  acute  aortic  regurgitation 
the  coronary  arteries  are  inadequately  filled,  the 
myocardium  is  enfeebled,  leading  to  a  feebler 
systole  and  increased  regurgitation.  In  course  of 
time  compensatory  hypertrophy  will  largely  make 
up  for  the  valvular  defect,  improving  the  coronary 
blood-supply,  promoting  the  nutrition  of  the 
myocardium,  and  enabling  the  heart,  even  though 
unsound,  to  carry  on  the  circulation  with  a  large 
measure  of  success  (JMatC  XVII I.  c). 

Another  example  is  seen  in  cases  of  portal  cirrhosis. 
In  this  disorder  large  numbers  of  hepatic  cells  are 
destroyed,  their  proteins  being  absorbed  into  the 
circulation,  producing  hepatic  anti-bodies  or  cytoly- 
sins,  which  lead  to  further  destruction  of  liver  cells. 
This  dangerous  toxic  process  may  be  checked  by 
hyperplasia  of  the  hepatic  parenchyma.  By  this 
means  the  evil  day  may  be  staved  off,  although 
there  is  always  a  danger  that  the  progressive 
cirrhotic  process  may  involve  the  hyperplastic  areas 
and  engulph  the  new  cells.1 

Cough.  So  physiological  an  act  as  coughing 
may  be  the  means  of  breaking  injurious  circular 
reactions,  as,  for  example,  when  tuberculous  matter 
is  evacuated  from  the  lung,  although,  owing  to  many 
collateral  factors,  such  a  fortunate  termination  is  not 
common.  When  a  tubercular  focus  has  formed  in 
the  pulmonary  tissues,  the  bacilli  give  rise  to 
enzymes  and  toxins,  which  weaken  and  destroy  the 
surrounding  cells  and  provide  increasing  supplies 
of  food  for  the  bacilli.  Thus  the  latter  multiply 
more  and  more,  and  give  to  tuberculosis  its  pro- 
gressive character.  Where,  however,  the  circum- 
stances are  favourable  and  the  tissues  have  adequate 

1  Rolleston,  Diseases  of   the  Liver,  Gall-Bladder  and  Gall- 
Ducts,  pp.  193,  292. 


Breaking  of  Circles  b£  IRature    297 

powers  of  resistance,  this  process  may  be  arrested. 
Indeed  the  whole  tuberculous  mass  may  be  loosened 
and  expectorated.  The  host  triumphs  over  the 
invader  and  the  morbid  process  is  at  an  end. 

EXTRA-ORDINARY   MECHANISMS 

At  other  times  some  extra-ordinary  mechanism  is 
called  into  operation  in  order  to  deal  with  the 
emergency. 

Emesis.  Biliousness  is  a  symptom-complex  due 
to  an  interwoven  chain  of  disordered  functions  in 
which  various  organs  are  involved.  It  frequently 
originates  in  some  error  in  diet  which  disturbs  the 
gastric  functions  and  sets  up  fermentation,  with  the 
production  of  lactic  and  butyric  acids,  which  irritate 
the  mucosa  and  cause  it  to  secrete  an  excess  of 
mucus  which  adds  fuel  to  the  fire.  The  irritated 
stomach  ceases  to  convert  its  contents  into  peptones 
and  chyme,  and  expels  into  the  duodenum  semi- 
digested  materials  entirely  unfit  for  intestinal  diges- 
tion and  absorption,  and  which  disorder  the  small 
intestines.  The  bile  and  pancreatic  juices  are  unable 
to  neutralise  the  gastric  juice  plus  the  lactic  and 
butyric  acids,  with  the  result  that  the  intestinal 
juices  remain  acid,  instead  of  becoming  alkaline, 
and  in  turn  irritate  the  mucosa  and  provoke  the 
secretion  of  unhealthy  mucus.  Simultaneously  with 
these  processes  angry  reflex  messages  are  travelling 
from  the  stomach  and  intestines  to  the  liver  and 
pancreas,  perverting  the  functions  of  these  glands 
and  interfering  with  the  due  discharge  of  their 
secretions.  Moreover  the  hepatic  antitoxic  functions 
are  largely  arrested,  so  that  the  organic  poisons 
which  reach  it  from  the  portal  system  continue  to 
circulate,  disturbing  the  functions  of  the  nervous 
system  and  giving  rise  to  headache,  giddiness  and 
other  symptoms.  Thus  the  primary  disorder  spreads 


298          Dicious  Circles  in  Disease 

far  and  wide,  with  echoing  reverberations  from 
one  organ  to  another. 

Nature  often  breaks  the  sequence  by  active 
emesis.  The  fermenting  ingest  a  together  with  the 
unhealthy  secretions  of  the  stomach  are  expelled,  so 
that  the  mucous  membrane  can  once  again  resume 
its  normal  activities.  The  liver  is  compressed  so 
that  the  inspissated  bile  is  squeezed  out  and  can 
once  again  take  part  with  the  pancreatic  juice  in 
intestinal  digestion.  The  reflex  disorders  in  the 
liver,  pancreas  and  other  organs  are  arrested  and 
the  complex  reciprocations  of  disturbed  functions 
come  to  an  end.  The  chain  of  interacting  disorders 
has  been  broken. 

A  similar  mechanism  may  operate  in  cases  of 
gastrectasis  where  dilatation  and  retention  aggravate 
each  other.  For  a  long  time  the  usual  reflexes  lie 
dormant  and  peristalsis  is  in  abeyance.  But  sooner 
or  later  the  burden  may  become  insupportable. 
The  machinery  of  vomiting  is  started  and  the 
stomach  pumps  up  its  contents,  perhaps  to  the 
extent  of  a  bucketful.  Even  a  greatly  dilated  sto- 
mach may  in  this  way  be  again  braced  up,  the 
unburdening  leading  to  great  amelioration  or  even 
to  recovery  (flMate  XVIII.  d). 

Peristalsis.  Attention  has  been  drawn  above 
to  the  sequence  of  events  occurring  during  the 
growth  of  a  biliary,  renal  or  other  calculus.  For 
years  the  morbid  correlations  may  persist,  while 
the  victim  endures  a  weary  martyrdom.  But  all 
at  once,  without  apparent  cause,  active  peristalsis 
may  be  called  into  operation  and  the  offending 
calculus  is  expelled.  Nature  has  done  the  trick 

(plate  xvni.  e). 

Again  in  obstinate  coprostasis  faecal  stasis 
may  lead  to  paralysis  of  the  intestinal  wall,  and 
the  paralysis  to  yet  more  obstinate  stasis.  Danger- 
ous correlations  are  in  operation  and  the  condition 


Breaking  of  Circles  b\>  IRature   299 

appears  one  of  impasse.  After  a  period  of  rest, 
however,  vigorous  peristalsis  may  return  and  sweep 
away  even  a  great  accumulation  of  faeces.  Such  an 
extraordinary  effort,  although  not  free  from  danger, 
may  be  completely  successful. 

Decompression.  Many  cases  of  heart  failure 
are  aggravated  by  secondary  visceral  congestion. 
Here  the  vis  medicatrix  may  take  the  form  of  a 
sharp  attack  of  gastric  or  intestinal  haemorrhage  ; 
indeed  such  a  loss  of  blood  is  often  a  blessing  in 
disguise,  and  prove  vitce  artifex,  mortis  fugator. 
On  the  one  hand  the  overburdened  heart  is  relieved 
while,  on  the  other  hand,  the  viscera  can  resume 
work  and  again  supply  wholesome  nutriment  to  the 
failing  myocardium.  The  lost  equilibrium  of  the 
vascular  system  is  restored  ((Mate  XVIII.  f). 

Uraemia  is  another  disease  in  which  haemorrhage 
is  common  and  frequently  beneficent.  Epistaxis, 
haematuria,  melaena,  metrorrhagia  may  occur.  Nature 
bleeds  herself  ;  the  organism  is  its  own  physician, 
as  Hippocrates  pointed, out  many  centuries  ago. 

Syncope.  In  other  cases  of  haemorrhage  dangerous 
correlations  may  be  interrupted  by  temporary 
cardiac  failure.  For  example,  in  pulmonary 
haemorrhage  the  intra-pulmonary  irritation  of  the 
effused  blood  causes  a  cough  :  each  act  of  coughing 
sends  up  the  blood-pressure  :  each  rise  of  blood- 
pressure  is  apt  to  renew  the  haemorrhage.  Under 
such  conditions  syncope,  instead  of  destroying, 
proves  the. very  means  of  preserving,  life.  The 
weakening  of  the  heart's  action  allows  time  for 
the  stagnating  blood  to  coagulate  within  the  bleeding 
vessel  and  close  the  orifice.  A  natural  haemostasis 
is  achieved. 

Inflammation.  The  self-perpetuating  processes 
that  complicate  ringworm  are  sometimes  arrested  by 
means  of  kerion.  Trichophytes  may  live  in  the 


300          IDidous  Circles  in  Disease 

skin  for  many  years  without  provoking  any  obvious 
reaction.  In  certain  cases,  however,  when  the 
tinea  tonsurans  has  penetrated  to  the  bottom  of  the 
hair  follicle,  an  inflammatory  reaction,  often  associ- 
ated with  pyogenic  organisms,  supervenes,  as  a 
result  of  which  the  hair  is  detached  from  its  papilla 
and  is  thrown  off  carrying  the  parasite  with  it. 
In  other  words  the  reaction  cures  the  disease  by 
expelling  the  parasite,  and  as  soon  as  this  has  been 
accomplished  the  reaction  subsides.  The  attacks 
of  ringworm  which  appear  the  most  severe  frequently 
have  the  most  favourable  termination. 

Sabouraud  describes  the  process  : 

"  There  is  a  whole  category  of  tineas  which  tend  to 
suppurative  folliculitis  and  give  rise  to  kerion.  In 
these  cases  an  afflux  of  leucocytes  takes  place  in  the 
follicle  and  provokes  the  loosening  of  the  hair,  which 
is  detached  from  its  papilla.  The  hair  then  acts  like 
a  foreign  body  and  is  spontaneously  expelled  or  else 
removed  by  the  slightest  traction.  In  these  cases 
epilation  is  automatic  and  recovery  fairly  rapid  ;  these 
are  tineas  which  soon  get  well.  I  call  them  autophagous 
since  the  extension  of  the  parasite  provokes  an  organic 

defence    which    brings    about    the    expulsion 

Kerions  cure  themselves  by  a  spontaneous  epilation."  1 

Kerion  is  only  one  example  of  the  inflammatory 
process  by  which  Nature  is  continually  breaking  the 
circuli  vitiosi  associated  with  injury  (cf.  p.  59). 

These  illustrations  may  suffice  to  shew  that  the 
resources  of  Nature  are  frequently  successful  in 
arresting  injurious  circular  reactions.  Her  meth- 
ods are  uncertain,  clumsy  and  painful  ;  never- 
theless they  often  accomplish  the  end  in  view. 
There  are,  however,  many  conditions  which  it  is 
beyond  her  power  to  cure.  Here  Art  must  succour 
Nature. 

aLes  Teignes,    p.    765. 


Chapter 


THE    BREAKING   OF   VICIOUS   CIRCLES 
BY   ART 

|  HE  breaking  of  Vicious  Circles  by  the 
ars  medica  is  so  extensive  a  subject  as 
to  require  a  special  treatise  if  anything 
like  justice  is  to  be  done  to  it  ;  physicians 
as  well  as  surgeons  are  perpetually 
engaged  in  breaking  Vicious  Circles.1  All  that  can  be 
attempted  here  is  to  focus  attention  on  therapeutics 
as  viewed  from  a  particular  standpoint.2 

The  treatment  of  disease  when  complicated  by 
the  citculus  vitiosus  presents  problems  peculiar  to 
itself.  The  physician  is  no  longer  confronted  with 
a  morbid  process  in  which  the  dominant  reactions 
are  beneficent  ;  these  reactions  are  feeding  the 
disorder.  The  vis  medicatrix  has  become  a  vis 
vastatrix,  and  what  looms  before  the  sufferer  is  at 
best  a  prolonged  disorder,  at  worst  a  descensus 
Averno.  One  teacher  writes: — "  I/et  it  be  a  cardinal 
principle  of  treatment  to  make  an  effort  to  interrupt 

1  The  treatment  of  "  Vicious  Circles  from  which  safe  emer- 

gence is  difficult  or  impossible,"  and  the  restor- 
ation of  disturbed  functional  equilibrium  is  dis- 
cussed by  Carter.  British  Med.  /.,  1900,  II.,  p.  1301. 

2  Doubtless  this  aspect  of  therapeutics  will  receive  more 

attention  in  the  future.  As  a  helpful  contribution 
may  be  mentioned  a  series  of  articles  by  Dr.  Sajous 
on  "  Vicious  Circles  in  Respiratory  Disorders  and 
their  Treatment."  New  York  Medical  /.,  1918,  II., 
PP-  344,  387,  43i,  475,  519,  564- 
301 


302 IDtctoue  Circles  in  ^Disease 

Vicious  Circles."1  Another  says  : — "  At  all  costs 
the  Vicious  Circle  that  has  been  established  must 
be  broken  through."2  Unfortunately,  however, 
our  text-books  give  but  little  assistance  in  the 
solution  of  the  special  problems  involved.  An 
attempt  must  therefore  be  made  to  discuss  the 
subject  of  treatment  as  influenced  by  the  presence 
of  circular  reactions  and  to  illustrate  the  procedure 
by  some  examples. 

Therapeutics  may  roughly  be  divided  into  (i)  the 
treatment  of  the  disease,  and  (2)  the  treatment  of 
symptoms.  Both  of  these  methods  are  concerned  in 
the  interruption  of  Vicious  Circles. 

The  more  important  task  of  the  therapeutist  is 
the  cure  of  the  actual  pathological  condition  from 
which  the  patient  is  suffering.  By  this  treatment, 
which  Gilbert  describes  as  "  therapeutique  patho- 
genique,  etiologique  ou  specifique — la  therapeutique 
des  causes,"3  the  cause  of  the  disease  is  attacked, 
and  when  this  can  be  accomplished  the  effects,  i.e. 
the  symptoms,  disappear.  Ablata  causa  tollitur 
effectus.  Its  difficulty  consists  in  the  discovery  of 
the  actual  morbid  processes  that  are  at  work,  and 
this  frequently  involves  a  long  and  arduous  search. 
Even  when  discovered  the  morbid  process  cannot 
always  be  arrested. 

The  other  method,  i.e.  symptomatic  treatment, 
appears  at  first  sight  to  be  the  easier  one.  Consti- 
pation is  treated  by  aperients,  haemorrhage  by 
haemostatics,  pain  by  sedatives,  fever  by  antipyretics 
and  so  forth.  To  such  symptomatic  treatment, 
however,  there  are  serious  draw-backs  which  may 
become  dangerous  if  it  be  indiscriminately  followed. 
Attention  is  concentrated  on  superficial  manifest- 

1M.  Bruce,  Principles  of  Treatment,  p.  263. 
2 British  Med.  /.,  1912,  II.,  p.  1459. 
3  Gilbert,  Clinique  Medicale,  pp.  34,  38 


ffbe  Breaking  of  IPIdous  Circles  b£  art    303 

ations  of  disease,  instead  of  on  its  fundamental 
factors.  Moreover  many  symptoms  are  the  outcome 
of  Nature's  beneficent  efforts  at  resistance  and 
reparation,  and  such  symptoms  must  be  carefully 
distinguished  from  other  injurious  manifestations. 
In  spite  of  its  attendant  dangers,  however, 
symptomatic  treatment  may  be  called  for  by  urgent 
conditions  which  threaten  life  or  provoke  acute 
suffering.  At  times  indeed  the  precise  nature 
of  the  disease  cannot  be  ascertained  ;  in  these 
and  similar  conditions  symptomatic  treatment  must 
be  resorted  to,  while  its  associated  perils  are  borne 
in  mind.1  Such  symptomatic  treatment,  some- 
times denounced  as  unphilosophical,  then  becomes 
the  height  of  wisdom  and  is  fully  justified  by  its 
results.  Sajous  has  so  well  described  symptomatic 
treatment  in  relation  to  Vicious  Circles  that  his 
remarks  may  be  quoted  in  full  : 

"  Interruption  of  a  Vicious  Circle,  intentionally  or 
unwittingly,  appears  sometimes  to  account  for  per- 
sistent benefit  from  purely  symptomatic  treatment 
which  could  not  otherwise  be  readily  explained.  Thus 
cough,  whatever  be  its  cause,  tends  to  produce  con- 
gestion of  the  lower  respiratory  passages.  This  con- 
gestion, in  turn,  promotes  local  irritability  and  tends 
to  increase  the  frequency  of  the  cough  paroxysms. 
These,  again,  augment  the  congestion,  and  a  Vicious 
Circle  thereby  results  which  tends  to  aggravate  and 
perpetuate  the  disturbance,  even  though  the  original 
cause — usually  some  form  of  local  irritation — has 
spontaneously  or  artificially  been  eliminated.  Admin- 
istration of  a  drug,  such  as  codeine,  to  depress  the 
cough  centres  in  cases  of  this  type,  would  at  first 
sight  appear  to  constitute  merely  symptomatic  treat- 
ment, the  beneficial  effects  of  which  will  disappear 
when  the  drug  is  discontinued,  the  irritative  cause 

admirable  account  of  the  advantages  and  dangers  of 
symptomatic  treatment  is  given  by  M.  Bruce.  Prin- 
ciples of  Treatment,  p.  135. 


304          HMcioug  Circles  in  ^Disease 

of  the  cough  persisting.     As  a  matter  of  fact,  however, 

the  codeine  in  addition  breaks  into  the  Vicious  Circle 

just  referred  to,  preventing  the  increase  of  cough  due 

to    local    congestion,    likewise    the    increase    of    local 

irritability  due  to  this  cough,  and  consequently  the 

aggravation    and    perpetuation   of    the   latter,    which 

would  otherwise  have  occurred  through  the  operation 

of  the  Vicious  Circle.     If  at  the  same  time  one  has 

succeeded  in  removing  the  irritative  cause  of  the  cough, 

complete  recovery  will  be  hastened  by  the  artificial 

interruption  of  the  Vicious  Circle  ;    even  if  one  has 

not,  the  benefit  from  the  remedy  will  be  far  more 

lasting  on  this  account  than  if  the  Vicious  Circle  has 

not  been  present  and  a  purely  symptomatic  effect  alone 

had  been  produced.     By  repeated  administration  of 

short  courses   of   codeine   treatment   the   evil    effects 

of  the  Vicious   Circle  can  be  continuously  obviated 

and,  through  the  consequent  removal  of  an  important 

factor  of  aggravation,  a  great  reduction  of  the  severity 

and  duration  of  the  disturbance  is  secured."  1 

As  soon  as  a  Vicious  Circle  has  been  recognised, 

an  effort  must  be  made  to  effect  a  breach  at  the 

locus   minor  is   resistentice,   for    a   signal   advantage 

presented  by  such  a  morbid  process  is  that  there  are 

at  least  two  points  at  which  the  evil  round  may  be 

attacked.     In    the    words    of    L,auder    Brunton  : — 

"  We  must  see  where  the  Circle  can  best  be  broken, 

since  if  we  break  the  Circle  at  one  point,  we  allow 

recovery  to  commence."     When  the  gyration  has 

been  stopped,  the  whirling  currents  will  be  restored 

to  their  normal  direction.     The  hound  which  had 

turned  to  hunt  its  own  tail  will  once  again  be  put  on 

the  track.     Each  practitioner  will  seek  to  effect  a 

breach  at  what  appears  to  him  the  point  of  election. 

One  will   attack  at  A,  another  at  B,  a  third  at  A 

and  B.     Hence  results  a  variety  of  methods  which 

at  times  puzzles  the  public,  especially  when  several 

practitioners  are  consulted  in  succession.     Yet  each 

1  New  York  Medical  /.,  1918,  II.,  p.  344. 


Breaking  of  Otctous  Circlee  bp  Hrt  305 

may  be  right  in  his  aims,  and  the  same  goal  may  be 
reached  by  different  routes.  Some  illustrations  of 
the  modus  operandi  may  be  grouped  under  the 
following  heads  :— 

I.  Hygienic  Measures 

II.  Drugs 

III.  Surgical  Appliances 

IV.  Surgical  Operations 

Fuller  details  as  to  the  Vicious  Circles  referred  to 
will  be  found  in  the  preceding  Chapters. 

I.     HYGIENIC   MEASURES 

The  ars  medendi  can  do  much  both  to  prevent,  and 
to  arrest,  injurious  reciprocations,  when  expert  know- 
ledge is  permitted  to  regulate  life  in  accordance  with 
physiological  righteousness.  Only  too  often,  how- 
ever, is  wholesome  advice  disregarded.  The  dictates 
of  fashion  and  the  love  of  self-indulgence  generally 
prevail  in  opposition  to  a  rational  regime. 

Rest.  The  prescription  of  rest  in  bed  is  often 
of  great  benefit.  Thus  in  various  forms  of  cardiac 
disorder  a  dilated  and  over-burdened  myocardium 
is  associated  with  pulmonary  and  visceral  engorge- 
ment, the  two  conditions  feeding  on  one  another 
under  the  stress  and  fatigue  of  the  daily  activities  of 
life.  Recumbency  relieves  the  heart,  the  warmth 
of  bed  stimulates  the  activity  of  the  skin  and  assists 
the  kidneys.  Improved  cardiac,  renal  and  hepatic 
activity  reacts  favourably  on  the  lungs  ;  the  relief 
of  pulmonary  congestion  further  invigorates  the 
heart.  All  these  cumulative  factors  tend  to  a 
better  circulation  and  a  more  aerated  blood.  Pure 
blood  spells  better  nutrition  of  the  nervous  system, 
and  so  by  degrees  all  the  organs  help  one  another 


3o6 IDicioug  Circles  in  ^Disease 

in  an  ascending  scale.  Brilliant  results  often  follow  the 
prescription  of  rest  in  bed  for  patients  threatened 
with  cardiac  failure  ;  even  seemingly  moribund 
persons  recover  and  continue  in  fair  health  for 
years  ((Mate  XIX.  a). 

I^auder  Brunton  emphasises  the  value  of  absolute 
rest  : 

"As  in  many  other  things  the  conditions  in  cardiac 
disease  form  a  Vicious  Circle.  The  disordered  circula- 
tion disturbs  the  function  of  other  organs,  and  these 
in  turn  make  the  circulation  worse.  .  .  In  such  cases 
it  is  evident  that  the  patient  is  bound  to  die,  and  to 
die  a  somewhat  painful  death,  unless  medical  art  can 
afford  him  some  assistance.  It  is  very  fortunate, 
however,  that  in  such  cases  medical  art  can  do  much. 
...  If  we  can  break  the  Vicious  Circle  at  one  point, 
we  allow  recovery  to  commence  ;  and  one  of  the  most 
important  agents — I  think  I  ought  to  say  the  most 
important  agent — in  the  physician's  power  is  absolute 
rest."  l 

It  must,  however,  be  remembered  that  there  should 
be  moderation  in  all  things,  and  that  so  valuable  a 
therapeutic  measure  as  rest  may  be  abused.  Exces- 
sive rest  may  induce  corpulence  and  throw  an  extra 
burden  on  the  heart.  A  careful  course  must  be 
steered  between  Scylla  and  Charybdis. 

In  other  disorders  mental  rest  is  required,  as 
for  example  in  some  forms  of  neurasthenia,  where 
business  worries  and  insomnia  are  interacting  factors 
A  holiday  in  Switzerland,  an  ocean  voyage  or  any 
similar  change  of  scene  that  gives  rest  to  the  exhaus- 
ted neurons  may  quickly  and  permanently  bring 
relief. 

Mental  repose  is  of  equal  importance  in  various 
forms  of  insanity  such  as  folie  circulaire. 

1  Therapeutics  of  the  Circulation,  p.  232.     Cf .  also  Faught, 
Blood-Pressure,  p.  438. 


fb^ienic  flfteaeuree 


307 


\Jenous 


*x 

(a)  CARDIAC  FAILURE 


(b)  OBESITY 


(c)  MALNUTRITION  (c)  HABITUAL  CONSTIPATION 


(e)  ACCUMULATION  OF  CERUMEN     (f)  NASAL  OBSTRUCTION 


plate  XIX.— She  iJBreafetng  of  the  Circle 
HDeaeuree. 


3o8 IDtdoug  Circles  in  Disease 

Clouston  writes  : 

"  The  great  point  in  treatment  is  to  prevent  the 
brain  getting  into  the  Vicious  Circle  of  continuous 
alternation,  by  endeavouring  really  to  complete  the  cure 
in  all  cases  of  mania — especially  in  all  cases  of  adoles- 
cent mania — and  to  enforce  prolonged  quiet  and  brain- 
rest  after  attacks  in  persons  who  have  shewn  a  tendency 
towards  recurrence  and  relapse." l 

Exercise.  The  old  proverb  "  What  is  one  man's 
food  is  another  man's  poison  "  applies  to  exercise 
as  well  as  to  food.  Increased  exercise  in  lieu  of  rest 
may  be  required  for  the  interruption  of  other 
circular  reactions.  A  common  illustration  is  afforded 
by  dyspeptic  disorders  associated  with  anorexia 
and  inertia.  Such  interacting  processes  may  often 
be  relieved  by  appropriate  exercise.  Tissue-hunger 
is  awakened,  psychical  appetite  returns,  active 
gastric  secretion  and  improved  nutrition  follow. 
The  Vicious  Circle  is  effectually  interrupted. 

Obesity  is  another  disorder  often  relieved  by 
exercise,  where  the  accumulated  fat  hinders  activity 
and  so  perpetuates  itself.  The  form  of  exercise 
to  be  prescribed  depends  on  the  degree  of  obesity 
and  the  individual  temperament.  Riding,  walking, 
home  gymnastics  may  all  render  service  under 
suitable  circumstances  (JMatC  XIX.  b).  Exercise, 
when  so  regulated  as  to  promote  cell  nutrition,  is  a 
valuable  means  of  strengthening  the  resistance  of 
the  body  in  tuberculosis,  and  thus  forms  a  valuable 
curative  measure.  The  severity  of  the  exercise 
must  of  course  depend  on  the  stage  and  activity 
of  the  disease.  But  when  the  temperature  is  steady 
at  a  normal  level  and  the  general  condition  is 
satisfactory,  the  exercise  may  be  gradually  increased 
with  advancing  convalescence.  Digestion  and  nutri- 
tion improve,  sleep  is  more  natural,  physique  is 
strengthened  and  resistance  to  toxins  is  increased. 

Cental  Diseases,  p.  245. 


t>\>dienic  (IDeaeures  309 

Nutrition.  The  regulation  of  nutrition  is  another 
valuable  therapeutic  measure.  Many  persons,  es- 
pecially young  women,  habitually  eat  too  little. 
Either  from  a  dread  of  corpulence,  from  want  of 
energy,  from  dyspepsia  or  other  cause  their  daily 
consumption  falls  below  their  expenditure.  Emaci- 
ation results  and  this  may  lead  to  increased  inertia 
and  dyspepsia. 

Mathieu  writes  : 

"  Many  of  these  patients  are  enclosed  in  a  veritable 
Vicious  Circle.  They  have  no  appetite  because  they 
are  insufficiently  nourished,  because  they  have  grown 
weak,  because  their  processes  of  metabolism  are  too 
greatly  reduced."1 

The  prescription  of  a  suitable  diet,  so  that  it  may 
include  a  sufficiency  of  protein,  fat  and  other 
constituents,  may  in  itself  suffice  to  restore  both 
mental  and  physical  vigour  (flMate  XIX.  c). 

Under  other  circumstances,  such  as  obesity, 
restriction  of  food  must  be  cautiously  imposed. 
The  corpulent  person  will  soon  begin  to  feel  the 
benefit  of  diminished  avoirdupois  ;  the  boulimia 
created  by  the  malady  will  be  less  imperious,  and 
after  a  few  weeks  the  patient  will  be  less  harassed  by 
his  self-denial.  Frequently  also  more  varied  and 
active  occupations  will  become  possible,  allowing 
less  leisure  for  self-indulgence  at  lengthy  meals. 
Some  limitation  in  the  amount  of  liquid  consumed 
will  help  in  the  same  direction.  Many  fat  persons 
imbibe  large  quantities  of  fluid  which  enable  them 
to  wash  down  their  food  rapidly  and  throw  an  extra 
burden  on  their  circulation.  Less  fluid  will  often 
cause  an  immediate  loss  of  several  pounds  owing  to 
a  relative  drying  of  the  body.  Such  diminished 
weight  with  the  concurrent  lessened  perspiration 

1  Maladies  de  1'Estomac  et  de  1'Intestin,  p.  447. 


IPidous  Circles  in  2>isease 


results  in  greater  comfort  and  allows  more  exercise 
to  be  taken. 

According  to  Haig  a  self-perpetuating  condition 
may  be  associated  with  a  diet  which  consists  too 
largely  of  meat.  The  meat,  in  his  view,  by  producing 
uric  acid  and  a  state  of  collaemia,  serves  as  a  stimu- 
lant, whose  action  is  succeeded  by  depression. 
For  the  relief  of  such  depression,  more  meat  is 
consumed,  and  if  this  fails  alcohol  is  resorted  to. 
A  vegetable  diet  produces  less  uric  acid  and  less 
depression,  and  thus  arrests  the  sequence. 

Haig  writes  : 

"  Vegetarianism  cuts  through  this  Vicious  Circle  by 
making  it  impossible  for  there  ever  again  to  be  any 
great  excess  of  uric  acid  in  the  blood,  and  so  removing 
a  cause  of  the  depression  which  leads  to  the  craving 
for  stimulants." 

And  again  : 

"  Meat  is  a  stimulant  whose  first  action  is  to  clear 
the  blood  of  uric  acid,  and  all  substances  that  produce 
this  effect  are  stimulants. 

Like  all  other  stimulants  it  produces  depression  later 
on  when  the  retained  uric  acid  passes  again  into  the 
circulation.  Hence  stimulant  taking  in  one  form  or 
another  is  an  inevitable  result  of  meat  eating,  and 
here  originates  the  demand  for  tea,  coffee,  alcohol, 
morphine,  cocaine,  to  counteract  the  secondary  depress- 
ing effects  of  the  original  stimulant. 

It  follows  that  there  is  no  escape  from  this  Vicious 
Circle  but  the  complete  abandonment  of  meat  and  all 
the  stimulants  that  have  been  brought  into  use  by 
it."1 

An  interesting  Circle  associated  with  nephritis 
and  ascites  can  often  be  interrupted  by  dietetic 
dechlorinisation.  In  some  forms  of  nephritis  the 

1  Uric  Acid  as  a  Factor  in  the  Causation  of  Disease,  pp.  242, 
303>  405,  407,  835,  846. 


1>£0ienic  Measures  311 

kidneys  lose  their  power  of  excreting  sodium 
chloride,  which  consequently  accumulates  in  the 
blood,  cellular  tissues  and  serous  cavities.  Owing 
to  the  influence  of  osmosis  a  considerable  quantity  of 
ascitic  fluid  may  collect  in  the  peritoneal  cavity, 
when  it  may  further  curtail  renal  efficiency. 

This  sequence  may  be  relieved  by  a  diet  con- 
taining a  diminished  proportion  of  salt.  For  ex- 
ample, a  purely  milk  diet  of  2-3  litres  per  diem  only 
contains  ca.  2j-5|  grms.  of  salt,  whereas  an  ordinary 
diet  contains  10-12  grms.  By  a  milk  diet,  therefore, 
a  gradual  dechlorinisation  may  be  brought  about. 
Milk  also  possesses  a  valuable  diuretic  action.  A 
similar  dechlorinisation  may  be  effected  if  solid  foods 
which  contain  but  little  sodium  chloride  are  con- 
sumed, such  as  meat,  eggs,  rice  and  potatoes. 

Hydrotherapy.  Many  disorders  liable  to  recur- 
rence are  associated  with  a  low  power  of  resistance, 
which  seems  to  grow  lower  with  every  attack  of 
disease.  For  example,  in  patients  subject  to  attacks 
of  bronchitis  the  skin  and  bronchial  tubes  become 
exceedingly  sensitive  to  changes  of  temperature,  the 
power  of  reaction  being  greatly  depressed.  Lowered 
resistance,  susceptibility  to  cold,  bronchitis,  lowered 
resistance — form  an  obstinate  sequence. 

Under  such  circumstances  a  careful  hardening 
regime  may  cure  the  liability  to  catarrh,  and  in 
that  regime  cold  baths  and  affusions,  if  used  with 
discretion,  are  of  great  value.  Indeed  such  cold  affu- 
sions may  establish  a  power  of  resistance  to  bronchial 
and  cutaneous  impressions,  where  debility  or  sensitive- 
ness previously  led  to  ever-recurrent  attacks  of 
catarrh. 

Regularity  of  Def  aecation.  Much  harm  is  done 
by  a  habitual  disregard  of  the  natural  call  to 
stool,  since  such  disregard  leads  to  progressive 
blunting  of  the  associated  reflexes  and  to  increased 


312          Dicious  Circles  in  Disease 

constipation.  Moreover  faeces  when  retained  in  the 
rectum  lose  much  of  the  fluid  constituents  by 
absorption,  and  produce  dry  and  hard  scybala 
which  are  difficult  of  expulsion  and  favour  retention. 
In  this  way  many  persons  contract  injurious  habits. 
The  adoption  of  such  a  diet  as  stimulates  the 
natural  desire  will  in  many  cases  suffice  to  regulate 
defalcation  and  arrest  the  bad  habit  that  has  been 
formed  (plate  XIX.  d). 

Cleanliness.  Numerous  disorders  have  been  men- 
tioned in  which  want  of  cleanliness  has  initiated 
disease,  which  in  its  turn  perpetuates  the  want  of 
cleanliness.  Amongst  these  are  pyorrhoea,  accumu- 
lation of  wax  in  the  auditory  meatus,  seborrhoea 
genitalium  and  intertrigo.  Appropriate  methods  of 
removing  stagnant  secretions  as  a  rule  readily 
check  the  morbid  correlations  (jplate  XIX.  e). 

The  same  principles  apply  to  those  parasitic 
disorders  in  which  infection  is  transferred  from  one 
region  to  another  by  the  fingers  and  thus  starts 
fresh  foci  of  disease. 

Breathing  Exercises.  Nasal  obstruction  and  the 
resulting  mouth-breathing  are  frequently  associated 
as  cause  and  effect.  For  example,  in  weakly 
children  nasal  secretions  are  allowed  to  accumulate 
and  block  the  nostrils  so  that  mouth-breathing  is 
resorted  to.  This  in  its  turn  favours  the  retention  of 
nasal  secretions  and  increases  the  nasal  obstruction. 
If  attended  to  early,  this  injurious  process  can  readily 
be  arrested.  By  an  efficient  use  of  the  pocket- 
handkerchief  or  by  induced  sneezing1  the  nasal 
passages  can  be  kept  clear,  while  the  habit  of 
nasal  respiration  is  carefully  inculcated.  Adenoid 
vegetations  would  be  less  common  if  such  nasal 
hygiene  received  greater  attention  (plate  XIX.  f). 

1  Lancet,  1918,  II.,  p.  240. 


313 


II.     DRUGS 

Many  Vicious  Circles  can  be  broken  with  the 
help  of  drugs,  provided  these  are  wisely  selected  and 
adapted.  The  deeper  the  insight  of  the  physician 
into  the  self-perpetuating  processes  that  are  in 
operation  the  more"  successful  will  be  his  treatment. 
Remedies  should  resemble  the  bullet  that  flies  from 
the  rifle  direct  to  the  bull's  eye  rather  than  the 
scattering  shot  of  the  fowling-piece. 

Space  will  only  permit  of  a  few  illustrations,  but 
these  will  suffice  to  indicate  the  modus  operandi. 
We  shall  deal  first  with  some  constitutional  dis- 
orders associated  with  the  nervous,  vascular,  diges- 
tive and  other  systems,  and  afterwards  with  local 
disorders. 

(A)    CONSTITUTIONAL    DISORDERS 

Pain  and  Insomnia.  Pain,  insomnia  and  a  lower- 
ed neuron  threshold  form  the  links  of  a  very  common 
and  grievous  concatenation,  which  is  met  with  in  vari- 
ous disorders,  each  link  being  both  cause  and  effect. 
An  aching  tooth,  a  tender  ovary,  an  over-taxed 
ciliary  muscle,  a  palpitating  heart  and  so  on  may 
fix  the  consciousness  of  the  sufferer  on  the  lesion, 
arouse  phobias,  produce  insomnia  and  steadily 
aggravate  both  suffering  and  misery.  Under  such  cir- 
cumstances the  administration  of  a  narcotic  which 
secures  sound  sleep  may  be  followed  by  such  rais- 
ing of  the  neuron  threshold  that  pain  vanishes  as 
with  the  wave  of  an  enchanter's  wand.  Evidently 
the  drug  acts  on  the  paths  by  which  a  lesion  affects 
consciousness  ;  probably  it  interrupts  those  paths 
at  their  synapses  in  the  region  of  the  great  cerebral 
ganglia.  When  irritability  has  been  diminished, 
the  stimuli  again  become  subliminal,  and  no  longer 
prevent  sleep.  The  sleep  further  diminishes  irrit- 
ability by  allowing  time  for  a  renewal  of  the  sub- 


3*4          Dictoug  Circles  in  ^Disease 

stances  consumed  by  the  discharge  of  energy,  and 
thus  raising  the  neuron  threshold  (JMatC  XX.  a). 

There  are,  of  course,  many  drugs  that  act  as  nar- 
cotics, but  in  efficiency  none  can  rival  morphia — 
TO  <f>dpfjiaKoi>  vr)iT€v@e<: — "the  soothing  drug." 

As  Mitchell  Bruce  says  : 

"  Rest  is  urgently  required  for  all  cases  of  this  kind, 
and  has  to  be  secured  in  many  instances  by  means  of 
morphine  which  breaks  the  Vicious  Circle  of  unrest 
and  irritability,  and,  a  beginning  once  made,  rest 
begets  rest."1 

Another  condition  in  which  sedatives  are  invalu- 
able is  what  has  been  called  the  "  most  highly  Vicious 
Circle  in  pathology,"  viz.  that  which  is  associated 
with  haemoptysis  and  haematemesis,  and  which 
largely  accounts  for  the  profuseness  and  prolongation 
of  haemorrhage.  Not  only  does  the  tendency  to 
cough  and  vomit  suffice  to  start  the  haemorrhage 
afresh,  but  the  associated  mental  perturbation  and 
physical  restlessness  raise  the  blood-pressure  and 
operate  in  the  same  direction.  The  morphia  or 
other  sedative  keeps  the  patient  quiet  mentally  and 
bodily,  thus  breaking  three  Circles  simultaneously, 
and  is  therefore  perhaps  the  most  valuable  drug  for 
controlling  haemorrhage. 

Morphia  is  of  course  only  a  type  of  various 
sedatives  that  may  be  used,  but  it  is  supreme  in  its 
power  of  dulling  over-excitability,  and  in  producing 
a  central  hypalgesia.  It  has  a  greater  power  than 
any  other  drug  "  sedare  dolor  em — divinum  opus." 

Epilepsy.  Certain  disorders,  such  as  epilepsy,  are 
associated  with  a  progressive  proclivity  to  paroxysms 
which  may  be  acquired  through  constant  repetition, 
the  attacks  being  probably  due  to  explosive  impulses 
arising  in  the  cerebral  cortex.  Every  attack  in- 

1  Principles  of  Treatment,  p.  230. 


Drugs 


315 


,«a5s 

I  /  V 


(a)  INSOMNIA 


(c)  CARDIAC  FAILURE 


(d)  ANEMIA 


(e)   HYPERCHLORHYDRIA 


(f)  SCABIES 


plate  \x.—Khe  Breaking  of  tbe  Circle 


316  IDidoug  Circles  in 


creases  the  labile  condition  of  the  nerve  centres  and 
after  being  effect  becomes  also  cause.  In  other 
words  the  neuron  threshold  is  gradually  lowered 
so  that  a  given  stimulus  more  and  more  readily 
provokes  a  paroxysm. 

Such  exaggerated  irritability  of  the  nervous 
system  can  be  controlled  by  bromides  ;  indeed  the 
prognosis  in  cases  of  epilepsy  has  been  revolutionised 
since  this  treatment  has  been  introduced.  In  a  few 
cases  there  are  no  further  attacks  even  when  the 
drug  is  discontinued  ;  the  bromide  may  then  be 
said  to  have  cured  the  disease.  In  the  large  majority 
of  cases  (90-95  per  cent.),  however,  the  frequency  of 
paroxysms  is  greatly  diminished,  or  the  patient  may 
be  entirely  free  as  long  as  the  treatment  is  kept  up, 
although  the  attacks  return  when  the  drug  is 
discontinued  (plate  XX.  b). 

Bromides  probably  exert  their  beneficial  influence 
by  retarding  the  passage  of  impulses  along  the 
paths  which  connect  the  various  motor  and  sensory 
centres  in  the  brain.  The  earlier  the  fits  are  arrested, 
the  less  fixed  will  be  the  proclivity  to  repetition. 
Even  in  the  status  epilepticus  the  drug  renders 
service,  although  that  status  has  other  self-per- 
petuating and  dangerous  complications  which  must 
not  be  neglected. 

Mott  thus  refers  to  the  status  epilepticus  : 

"  To  stop  the  fits  early  and  prevent  the  establish- 
ment of  the  Vicious  Circle  by  chloral  or  bromide  ;  to 
relieve  venous  congestion  by  purgation  or  enemata  ;  to 
support  the  heart  by  nutrient  enemata  and  stimulants, 
and,  if  necessary,  relieve  the  engorged  distended  right 
heart  by  venesection,  appear  to  be  the  rational  mode 
of  treatment.  When  people  die  in  the  status  epilep- 
ticus it  is  often  because  these  measures  have  not  been 
adopted  soon  enough."  1 

1  Archives  of  Neurology,  I.,  p.  502. 


Drugs  317 

Paralysis.  In  various  forms  of  paralysis,  such 
as  those  due  to  acute  anterior  poliomyelitis,  there 
is  a  progressive  increase  of  the  disorder  owing  to  loss 
of  the  reciprocal  relations  between  the  tropho-motor 
neurons  and  their  corresponding  muscle  cells.  These 
two  elements  form  but  a  single  unit  ;  disease  of 
the  one  involves  disease  of  the  other.  Sometimes 
the  damaged  neurons  are  unable  to  transmit  any 
impulses  down  to  the  muscles  ;  at  other  times 
these  impulses  are  too  feeble  to  evoke  any  responsive 
contraction.  In  either  case  the  absence  of  response 
checks  the  nutrition,  and  delays  the  recovery,  of  the 
neurons. 

In  such  conditions  the  elective  action  of  strychnine 
on  the  reflex  arcs  of  the  nervous  system  is  most 
valuable.  Even  small  doses  may  so  raise  the 
irritability  of  the  neurons  that  they  may  again 
become  susceptible  to  peripheral  stimuli  from  the 
muscles,  nutrition  and  repair  thus  being  promoted. 
The  activities  of  the  receptive  organs  in  the  cord  and 
brain,  which  have  been  depressed  by  degenerative 
processes  may  in  some  measure  be  restored,  so  that 
the  reflex  mechanism  again  responds  to  physiologi- 
cal stimuli. 

The  action  of  the  strychnine  is  probably  localised 
at  some  point  between  the  entrance  of  the  affected 
fibre  and  the  synapse  of  the  motor  cell.  At  that 
point  the  passage  of  impulses  through  some  of  the 
synapses  of  the  spinal  cord  is  facilitated. 

Shock.  In  surgical  shock  various  reciprocally 
acting  conditions  are  present,  including  a  depleted 
arterial  and  an  engorged  venous  system,  combined 
with  a  low  blood-pressure  and  a  feeble  cardiac 
activity.  As  a  consequence  the  vaso-motor  centres 
are  inadequately  nourished  with  blood  and  in 
severe  cases  rapidly  lose  their  control  over  the 
circulation.  In  other  words  the  fall  of  blood- 
pressure  and  the  inactivity  of  the  vaso-motor  centres 


3*8  IDictoug  Circles  in 


re-inforce  each  other,  and  the  reciprocally  acting 
process  frequently  ends  in  death.  Under  such 
conditions  the  intr  a-  venous  injection  of  adrenalin 
constricts  the  small  blood-vessels  and  raises  blood- 
pressure.  Indeed  a  full  dose  of  the  drug  may 
drive  a  large  volume  of  blood  into  the  arterial 
system  and  flood  the  tissues  with  blood,  while 
at  the  same  time  it  strengthens  the  cardiac  systole 
by  stimulating  the  myocardium.  In  both  these 
ways  the  drug  may  break  the  Vicious  Circle  associ- 
ated with  shock  and  prevent  what  appears  imminent 
death.  In  recent  years  adrenalin  has  become  one 
of  our  most  valued  remedies  owing  to  the  reliability 
of  its  action. 

Cardiac  Failure.  Circulatory  insufficiency  may 
result  from  disease  of  the  myocardium  or  of  the 
valves,  when  the  resulting  interference  with  the 
circulation  is  not  adequately  compensated.  The 
principal  compensatory  change  is  brought  about 
by  hypertrophy  of  the  muscles  of  one  or  more  of 
the  cardiac  chambers,  which  are  thus  able  to  pump 
out  the  blood  in  sufficient  quantity  and  with  suffi- 
cient force  to  supplement  any  deficiency  in  the  circu- 
lation. L,ater  on,  however,  as  a  result  of  progressive 
valvular  or  myocardial  disease  or  of  impaired  nu- 
trition, compensation  usually  breaks  down,  and  stasis 
supervenes  in  the  pulmonary  or  systemic  circuit  or 
in  both,  with  secondary  results  —  pulmonary,  systemic 
and  portal  congestion,  ascites,  oedema  etc.  —  all  of 
which  aggravate  the  cardiac  failure. 

Under  such  conditions  digitalis  and  other  plants 
of  the  digitalis  series  yield  the  sovereign  remedy  for 
breaking  the  dangerous  Circles  that  have  become 
established  (plate  XX.  c). 

A  ventricle  which  has  become  insufficient  can 
under  the  influence  of  digitalis  regain  sufficiency. 
The  immediate  effect  of  this  will  be  an  improved 
coronary  circulation  which  in  its  turn  will  promote 


319 


a  more  vigorous  systole.  There  will  also  be  a  lower- 
ing of  the  excessive  peripheral  vaso-constriction 
which  has  been  provoked  by  the  medullary  centres 
in  order  to  keep  themselves  supplied  with  blood, 
but  which  is  no  longer  required.  This  will  lighten 
the  burden  imposed  on  the  failing  myocardium. 
Thus  is  brought  about  an  improvement  both  in  the 
vis  a  tergo  and  in  the  vis  a  f  route,  as  a  result  of  which 
the  blood  which  had  accumulated  in  the  venous 
system  flows  more  freely  to  the  heart  and  arteries, 
thus  further  benefiting  the  myocardium.  The  con- 
dition of  the  blood  also  improves  since  the  impaired 
processes  of  secretion,  excretion  and  aeration  are 
invigorated,  and  the  purer  blood  tends  to  more  active 
nutrition. 

Another  effect  of  digitalis  is  to  increase  the  tone 
of  the  myocardium  and  thus  to  moderate  tachy- 
cardia. An  enfeebled  myocardium  is  compelled 
to  beat  rapidly  in  order  to  carry  on  the  circulation, 
even  though  such  rapid  action  leads  to  progressive 
weakening,  since  the  cardiac  chambers  can  neither 
fill  nor  empty  themselves  as  they  should.  With 
increased  tonicity  the  systolic  output  is  increased, 
so  that  fewer  beats  are  required. 
Pavlov  writes  : 

"  An  uncompensated  heart  beats  rapidly  and  thereby 
only  aggravates  its  condition.  Its  time  of  rest,  that 
is  of  recovery,  of  restitution  of  the  organ  is  shortened. 
A  Vicious  Cycle  is  set  up.  The  weak  action  of  the 
heart  lowers  blood-pressure,  the  lowering  of  this  leads 
(from  known  physiological  causes)  to  an  increase  in  the 
number  of  beats,  the  quickening  leads  to  weakening  of 
the  organ.  Without  doubt  the  digitalis  aids  by  break- 
ing through  this  Vicious  Cycle  in  that  it  greatly  slows 
the  pulse,  and  thereby  gives  new  power  to  the  heart."1 
This  slowing  action  of  digitalis  is  especially 
beneficial  in  auricular  fibrillation,  and  may  be  due 

1  The  Work  of  the  Digestive  Glands,  p.  233. 


32Q IDiclous  Circles  in  SDtseage 

to  a  retarding  action  on  the  conductivity  of  the 
bundle  of  His  and  to  a  diminished  irritability  of 
the  motor  ganglia  in  the  heart. 

As  a  result  of  the  improved  tonicity  the  auricular 
and  ventricular  orifices  contract,  and  this  enables 
the  valves,  even  though  damaged,  to  close  the 
orifices  more  effectually  and  thus  to  lessen  regurgita- 
tion  ;  there  is  also  less  tendency  to  over-distention 
during  diastole.  The  increased  diuresis  brought 
about  by  digitalis  is  of  further  benefit  by  relieving 
the  general  oedema  which  so  often  complicates 
cardiac  failure,  and  throws  so  much  extra  work 
on  the  myocardium.  The  kidneys  share  in  the 
general  acceleration  of  the  blood-flow  and  secrete 
more  vigorously.  The  accumulated  fluid  in  the 
tissues  tends  to  return  to  the  blood-vessels  and 
to  be  excreted  by  the  kidneys.  With  diminishing 
ascites  the  pressure  on  the  renal  veins  is  relieved 
and  so  progress  is  accelerated. 

Thus  in  various  ways  digitalis  renders  brilliant 
service  in  cases  of  cardiac  failure  ;  no  wonder 
that  it  is  regarded  as  a  sheet-anchor.  Many  other 
drugs  are  also  of  value  ;  digitalis  has  merely  been 
selected  as  a  type. 

Opotherapy  has  also  at  times  been  used  with 
success.  Some  cases  of  cardiac  failure,  which 
Martinet  has  termed  (<hyposphyxia,"  appear  to  be 
complicated  by  hypo-endocrinism,  which  may  be 
advantageously  treated  by  suitable  pluriglandular 
extracts,  in  conjunction  with  physical  and  other 
means  calculated  to  strengthen  the  circulatory 
function.  Martinet  believes  that  in  these  cases 
"  there  is  a  digestive  disorder  which  reacts  upon  the 
circulatory  disturbance  and  forms  a  Vicious  Circle." 
He  therefore  treats  it  with  secretin  preparations,  and 
and  at  the  same  time  relieves  the  endocrinous 
dyscrasia  by  pituitary  or  adrenal  extracts,  combined, 
where  necessary,  with  thyroid  and  ovarian  extracts. 


321 


Excellent  results  are  said  to  be  obtained  from  such 
opotherapy  in  cases  of  hyposphyxia  following  acute 
infectious  diseases,  malnutrition,  neurasthenia  and 
in  the  pretuberculous  state.  "  The  primary  Vicious 
Circle  is  broken  by  this  treatment."1 

Angina  Pectoris.  Angina  pectoris  is  another 
disorder  which  is  frequently  complicated  by  a 
Circle,  and  for  which  amyl  nitrite  is  used.  The  drug 
is  most  successful  in  the  form  of  paroxysm  known  as 
"  angina  pectoris  vasomotoria,"  i.e.  attacks  of  vaso- 
constriction  associated  with  a  high  blood-pressure. 
In  such  cases  the  effects  of  amyl  nitrite  are  unsur- 
passed in  certainty. 

Allbutt  describes  this  form  of  angina  : 

"  Vaso-constriction  often  becomes  an  active  part  of 
angina.  A  movement  or  an  emotion  raises  arterial 
pressure  ;  by  this  the  sore  parts  are  annoyed  and, 
the  medullary  centres  being  irritated,  pressures  may 
rise  more  and  more,  and  a  Vicious  Circle  be  established 
until  by  nitrites  pressures  are  reduced,  or  by  morphia 
the  centres  blocked."2 

When  administered  in  the  form  of  an  inhalation, 
the  drug  gives  speedy  relief,  sometimes  in  less  than  a 
minute,  and,  although  the  vaso-dilation  brought 
about  may  only  be  temporary,  the  distressing 
symptoms  may  be  arrested  for  a  considerable  period. 

Other  nitrites,  such  as  sodium  nitrite,  exert  a 
similar  effect  to  amyl  nitrite,^  although  their  use  is 
less  convenient.  On  the  otlier  hand  their  effect 
may  last  longer. 

Martinet,  Traitement  des  Hyposphyxies,  Presse  Medicate, 
1913,  XXI.,  p.  635.  Cf.  also  narrower,  Practical 
Hormone  Therapy,  p.  421. 

2  Diseases  of  the  Arteries,  including  Angina  Pectoris,  II., 
p.  236. 


323          Melons  Circles  in 


Anaemia.  Anaemia  is  frequently  a  self-perpet- 
uating condition  through  its  effects  reacting  upon 
and  aggravating  the  cause.  Hence  the  chronicity 
of  the  disorder. 

The  administration  of  iron  seems  beneficial  in  all 
forms  of  primary  anaemia,  and  arrests  the  recipro- 
cally acting  correlations.  It  is  in  the  chlorotic 
form,  however,  that  the  drug  achieves  its  most 
brilliant  triumphs.  Few  drugs  can  be  more  con- 
fidently relied  upon  to  interrupt  the  reciprocations 
associated  with  a  disease  ;  a  large  proportion  of 
sufferers  recover  completely.  "  There  is  absolutely 
no  question  that  administration  of  iron  restores  the 
composition  of  the  blood  to  normal,  usually  quite 
rapidly  "  (plate  XX.  d). 

In  chlorosis  there  is  always  a  deficiency  of 
haemoglobin  and  usually  a  deficiency  of  red  blood  cor- 
puscles, disorders  which  may  be  due  to  insufficient  food 
or  to  excessive  menstrual  loss.  In  a  healthy  woman's 
diet,  the  average  daily  amount  of  iron  is  only  6-8 
mgrms.  (jV-g  gr.),  and,  as  this  only  just  balances 
the  excretion,  a  very  small  margin  is  left  for  haemo- 
poiesis. If,  therefore,  the  average  intake  is  reduced 
by  dyspepsia  or  if  the  output  is  increased  by 
menorrhagia,  the  body  gradually  becomes  depleted 
of  iron  and  the  haemoglobin  is  the  constituent  which 
suffers  most.  Hence  result  breathlessness,  cardiac 
weakness  and  oedema. 

When,  however,  iron  is  taken  in  addition  to  that 
contained  in  the  ordinary  food,  haemopoietic  activity 
is  gradually  increased,  and  both  the  proportion  of 
haemoglobin  and  the  number  of  red  corpuscles  in- 
crease. 

The  value  of  iron  has  been  established  not  only 
clinically  but  by  experiments  on  the  lower  animals, 
which  show  that  the  drug  may  not  only  be  utilised 
as  material  for  the  synthesis  of  haemoglobin  but  also 
exerts  a  specific  action  on  the  blood-marrow  and 


323 


other  blood-forming  organs.1  The  combinations  of 
iron  as  met  with  in  chalybeate  waters,  such  as  those 
of  Spa  or  St.  Moritz,  are  often  highly  efficient  in 
arresting  the  morbid  process.1 

Bronchitis.  Recovery  from  bronchitis  largely 
depends  on  the  success  with  which  natura  medicatrix 
can  get  rid  of  the  large  quantity  of  mucus  and  other 
secretions  which  are  poured  out  into  the  bronchial 
tubes  and  which  tend  to  obstruct  the  free  passage  of 
air.  Such  expulsion  is  brought  about  by  means 
of  the  ciliated  epithelium  and  of  cough,  which 
tend  to  remove  impurities  from  the  lungs. 

In  severe  attacks  of  bronchitis,  however,  these 
natural  agencies  fail  to  achieve  their  object.  The 
retained  secretions  become  infected  with  bacteria, 
and  destroy  the  ciliated  epithelium.  Bronchiec- 
tasis  and  emphysema  may  also  supervene  with 
impaired  power  of  expectoration.  Often  indeed 
the  bronchiectasis  causes  stasis  and  vice  versa. 

These  various  circular  reactions  may  be  more  or 
less  broken  by  expectorants.  Some  drugs,  e.g. 
carbonate  of  ammonia,  stimulate  ciliary  action  and 
assist  in  the  removal  of  secretion,  or  excite  the 
unstriped  bronchial  muscles  which  expel  the  secre- 
tions from  the  alveoli  into  the  bronchial  tubes. 
Others,  such  as  ammonium  chloride,  facilitate  the 
removal  of  secretions  by  increasing  their  alkalinity. 
Yet  others,  such  as  terebene  or  turpentine,  may 
exert  some  disinfectant  action  and  check  bacterial 
growth  .  Ipecacuanha  both  increases  bronchial  secre- 
tions and  renders  them  more  liquid,  so  that  the 
mucus  can  be  more  easily  expectorated.  Moreover 


1  Chlorosis  in  plants  is  due  to  an  insufficiency  of  iron  in  the 
green  chlorophyll  of  plants,  and  can  be  cured  by  the 
administration  of  iron.  Ward,  Disease  in  Plants,  p. 
180. 


324  IDictous  Circles  In  2)tsea6e 

the  increased  secretions  sometimes  do  good  by 
protecting  the  inflamed  and  irritable  mucosa  from 
cold  air  and  renewed  catarrh.  Where  it  is  desirable 
to  liquefy  tenacious  phlegm,  creosote  or  benzoin 
may  be  used  in  an  inhaler  or  a  nebulizer.  In  all 
these  ways  injurious  circular  reactions  may  be 
arrested. 

Asthma.  Asthma  is  another  respiratory  disorder 
complicated  by  a  circulus  vitiosus,  which  can  often 
be  broken  by  drugs.  "  Emphysema,  bronchial 
catarrh  and  diseases  of  the  right  heart  all  increase 
the  tendency  to  asthmatic  attacks,  which  in  turn 
increase  the  severity  of  the  complications,  and  so 
the  patient  lives  in  a  Vicious  Circle."1 

No  single  drug  succeeds  in  arresting  the  paroxysms 
in  every  form  of  asthma.  But  stramonium,  nitrate 
of  potash,  chloroform,  morphia  may  all  act  as 
specifics  under  certain  circumstances.  By  arresting 
the  paroxysms  they  relieve  the  correlated  disorders 
which  tend  to  bring  on  the  attacks. 

The  value  of  codeine  in  breaking  the  Vicious 
Circle  of  cough  and  congestion  has  already  been 
alluded  to  (cf.  p.  303). 

Anorexia.  Amongst  the  commonest  of  disorders 
of  daily  life  is  anorexia  or  loss  of  appetite  which  may 
arise  from  a  variety  of  causes. 

In  a  person  enjoying  good  health  the  following 
sequence  of  events  establishes  a  circulus  virtuosus, 
or  what  Mathieu  and  Roux  term  a  "  reflex  physio- 
logical Circle,"  in  which  both  central  and  peripheral 
reactions  take  part.2 


1  Short,  Index  of  Prognosis,  p.  132. 

2  Mathieu  and    Roux,  Pathologic  Gastro-Intestinale,  Series 

IV.  (1913),  pp.  23,  35. 


325 


The  ordinary  activities  of  life  arouse  what  is 
known  as  tissue  hunger  due  to  the  need  for  nutritive 
materials  to  replace  those  that  have  undergone 
combustion.  This  tissue  hunger  rapidly  provokes 
a  cerebral  condition  which  makes  itself  felt  as 
appetite,  and  is  followed  by  a  flow  of  digestive 
juices  (appetite  juice).  The  secretion  of  such  juices 
in  its  turn  reacts  on  the  brain  and  further  stimulates 
the  sense  of  appetite.  If  a  good  meal  is  now  enjoyed, 
rapid  assimilation  follows,  nutrition  is  promoted, 
arousing  a  desire  for  exercise,  which  in  its  turn 
awakens  fresh  tissue  hunger  and  so  completes  the 
round. 

Under  various  circumstances,  however,  this  se- 
quence is  disturbed  and  we  get  in  its  place  languor, 
absence  of  tissue  hunger,  want  of  appetite,  deficiency 
of  gastric  secretion,  nausea  at  the  sight  of  food, 
impaired  nutrition,  disinclination  for  exercise  and 
languor.  Obviously  several  arcs  of  the  Circle  can 
be  attacked.  Active  exercise,  psychical  influences  or 
drugs  may  all,  under  suitable  circumstances,  interrupt 
the  evil  concatenation.  Here  we  are  merely  con- 
cerned with  drugs.  Bitter  preparations  introduced 
into  the  stomach  have  long  been  known  to  possess 
the  power  of  exciting  the  appetite.  This  is  followed 
by  a  flow  of  gastric  juices  which  in  their  turn  further 
stimulate  the  appetite.  Consequently  more  food 
is  taken,  and  this  is  followed  by  improved  nutrition, 
increased  vigour  and  a  desire  for  exercise.  From  such 
exercise  result  increased  metabolism,  tissue  hunger 
and  further  appetite,  the  circulus  vitiosus  being  re- 
placed by  a  circulus  virtuosus. 

The  value  of  such  bitters  as  strychnine,  quinine, 
gentian  and  quassia  is  thus  readily  intelligible.1 

Chronic  Gastritis.  Chronic  gastritis  is  often 
complicated  by  impaired  secretion,  absorption  and 

Pavlov,  The  Work  of   the  Digestive  Glands,  pp.  94,  225. 


326  IDicious  Circles  in  Disease 

peristalsis,  these  several  factors  aggravating  each 
other.  Ewald  has  admirably  described  the  recipro- 
cation of  events  (cf.  p.  93). 

Such  a  self-perpetuating  form  of  gastritis  is 
frequently  cured  by  the  administration  after  meals 
of  dilute  hydrochloric  or  other  mineral  acid,  with 
which  a  suitable  diet  must  of  course  be  combined. 
It  is  not  certain  in  what  way  the  drugs  act.  Accord- 
ing to  Cushny  the  acid  both  arrests  the  lactic 
fermentation  which  is  so  often  present,  and  increases 
peristalsis.  At  any  rate  patients  often  express 
themselves  as  immensely  benefited  by  the  remedy, 
to  which  some  physicians  have  attributed  their 
great  success  in  curing  chronic  dyspepsia. 

Hyperchlorhydria.  A  remarkable  circular  reac- 
tion is  sometimes  associated  with  what  is  known  as 
Reichmann's  syndrome,  in  which  stasis,  hyper- 
chlorhydria  and  pyloric  spasm  reciprocally  per- 
petuate each  other.  The  syndrome  is  characterised 
by  paroxysms  of  severe  pain  coming  on  three  or 
four  hours  after  meals  and  probably  connected  with 
spasm  of  the  pylorus.  In  these  cases  a  dose  of 
bicarbonate  of  soda  frequently  gives  immediate 
and  complete  relief,  by  neutralising  the  excess  of 
acid,  followed  by  relaxation  of  the  spasm,  the 
retained  food  being  thus  enabled  to  pass  into  the 
duodenum  (plate  XX.  e). 

Another  plan  recommended  by  Mathieu  is  the 
administration  of  the  alkali  in  small  doses  as  soon 
as  the  approach  of  pain  is  felt,  the  dose  being  re- 
peated every  five  minutes  until  the  spasm  ceases.1 

The  attacks  of  pain  may  often  be  completely 
arrested  by  such  a  treatment  extending  over  a  few 
days. 

1  Mathieu  and  Roux,  Pathologic  Gastro-Intestinale  (1913), 
Series  IV.,  pp.  90,  96,  98. 


Drugs  327 

Cast  recta  sis.  An  obstinate  Vicious  Circle  may 
complicate  the  condition  of  chronic  dilatation  of 
the  stomach  associated  with  prolonged  retention  of 
food.  The  dilatation  conduces  to  stasis  and  the 
stasis  to  dilatation.  The  administration  of  an 
emetic  such  as  ipecacuanha  or  sulphate  of  zinc  may 
at  once  arrest  these  reciprocating  factors.  Even  a 
greatly  dilated  and  over-loaded  stomach  may  again 
be  braced  up,  the  unburdening  being  followed  by 
renewed  tonicity  and  functional  activity.  The 
emesis  relieves  the  stasis,  the  relief  of  the  stasis 
cures  the  gastrectasis. 

Habitual  Constipation.  Habitual  constipation 
is  frequently  due  to  a  neglect  of  the  natural  call,  the 
resulting  retention  of  faeces  being  followed  by  an 
undue  absorption  of  their  fluid  constituents.  The 
reduced  mass  of  dry  faeces  is  then  unable  to  excite 
adequate  peristalsis,  so  that  there  is  an  interplay  of 
cause  and  effect  which  accounts  for  the  obstinate 
coprostasis  that  is  so  often  met  with. 

This  circular  reaction  is  readily  interrupted  by  a 
saline  cathartic,  such  as  sodium  sulphate,  which, 
being  but  slowly  absorbed  by  the  intestines,  entails 
the  simultaneous  slow  absorption  of  the  water  in 
which  the  drug  is  dissolved.  If  therefore  a  dose 
of  sodium  sulphate  dissolved  in  water  is  administered, 
a  greater  quantity  of  water  will  reach  the  large 
intestine  than  when  a  similar  quantity  of  pure 
water  is  drunk.  The  intestinal  contents  are  thus 
rendered  more  fluid  than  usual,  and  pass  more 
easily  on  towards  the  rectum.  At  the  same  time 
the  bulk  of  fluid  and  the  distention  of  the  bowel 
promote  a  more  active  peristalsis  and  the  whole 
alvine  contents  are  easily  evacuated.  Many  mineral 
waters  such  as  Carlsbad  and  Hunyadi  Janos  owe 
their  efficiency  to  the  presence  of  sodium  sulphate. 

Another  invaluable  drug  for  habitual  constipation 
is  cascara  sagrada,  since  it  not  only  empties  .the 


328  IDtdoug  Circles  in 


bowel  of  faecal  matter  but  simultaneously  acts  as  a 
tonic  to  the  intestinal  walls,  and  thus  prevents  the 
constipation  which  follows  the  use  of  most  aperients. 

Parasitic  Infection.  Parasitic  infection  of  the 
intestines  occasionally  establishes  circular  reactions 
which  may  be  arrested  by  drugs. 

A  familiar  illustration  is  presented  by  oxyuriasis, 
a  disorder  in  which  continual  reinfection  occurs  as  a 
result  of  the  anal  irritation.  Such  irritation,  especially 
in  children,  leads  to  infection  of  the  fingers  with  ova 
which  are  then  liable  to  be  transferred  to  the  mouth, 
and  eventually  regain  the  intestines. 

This  Circle  may  be  broken  by  enemata  of  quassia. 
But  since  the  parasites  lodge  mainly  in  the  caecum 
and  continue  to  descend  into  the  rectum  in  successive 
swarms  during  the  last  four  or  five  out  of  the  six  or 
seven  weeks  following  a  single  infection,  the  treat- 
ment, to  be  permanently  successful,  must  extend 
over  this  period  as  a  minimum.  A  pint  of  quassia 
infusion  for  an  adult  or  five  ounces  for  a  child  will 
destroy  such  worms  as  are  lodged  in  the  rectum, 
and  as  soon  as  all  the  parasites  have  descended 
from  the  caecum,  and  have  been  killed  by  further 
injections,  a  radical  cure  ought  to  be  effected, 
provided  that  no  fresh  auto-infection  has  been 
allowed. 

The  irritation  round  the  anus  may  be  relieved 
by  the  use  of  a  weak  mercurial  ointment  or  by 
sponging  with  carbolic  lotion. 

Nephritis.  Nephritis  is  frequently  a  self  -per- 
petuating condition  owing  to  the  secondary  retention 
of  toxins,  which  in  their  turn  further  impair  renal 
activity.  Toxaemia  may  thus  be  both  cause  and 
effect  of  nephritis. 

The  reciprocation  may  at  times  be  successfully 
interrupted  by  a  profuse  diaphoresis  which  withdraws 
large  quantities  of  water  together  with  salts  and 


Drugs  329 

toxins  by  way  of  the  skin,  and  thus  brings  relief 
to  the  kidneys. 

One  of  the  best  drugs  for  the  purpose  is  pilo- 
carpine,  by  far  the  most  powerful  sudorific  in  the 
pharmacopoeia,  and  one  which,  if  injected  hypoder- 
mically,  usually  produces  profuse  sweating  in  ten  or 
fifteen  minutes.  The  diaphoresis  lasts  about  two 
hours  during  which  as  much  as  two  kilos,  of  fluid 
may  be  excreted.  The  functional  activity  and 
nutrition  of  the  kidneys  are  often  greatly  promoted 
and  the  injurious  reactions  arrested.  The  use  of 
such  an  aperient  as  magnesium  sulphate  assists 
the  sudorific  by  eliminating  impurities  by  the  bowel 
and  thus  further  relieving  the  toxsemia. 

I^angdon  Brown  points  out  that  diaphoresis  may 
be  helpful  in  breaking  the  Circle  associated  with 
chloridaemia  : 

"  Here  we  have  the  clue  to  the  kind  of  case  in  which 
diaphoresis  will  be  of  service — namely  that  in  which 
there  is  a  defect  in  the  elimination  of  sodium  chloride 
with  consequent  oedema,  for  the  retained  salt  increases 
the  osmotic  pressure  of  the  tissues,  and  this  tends  to 
increase  oedema  and  to  diminish  excretion.  The 
elimination  of  salt  by  the  skin  may  therefore  be  of 
indirect  service  by  breaking  a  Vicious  Circle."  ' 

Diphtheria.  Space  only  permits  of  a  brief 
reference  to  serum  treatment.  A  notable  illustration 
is  afforded  by  the  use  of  anti-diphtheritic  serum, 
which  neutralises  the  toxins  in  the  tissues  and  thus 
arrests  their  pernicious  effects.  In  other  words  the 
serum  prevents  the  death  of  the  cells  on  which  the 
bacilli  are  growing.  These  protected  cells  therefore  are 
able  to  resist  the  invaders,  and  as  a  result  the  local 
lesion  improves  rapidly.  The  fatal  tendency  to 
extension  is  arrested  (cf.  p.  201). 

'Physiological  Principles  in  Treatment,  p.  208. 


33Q IDidoug  Circles  in  Disease 

Tuberculosis.  An  example  of  vaccine  therapy 
is  afforded  by  tuberculin  which  now  asserts  its 
claim,  more  modest  than  that  originally  and 
arrogantly  asserted,  of  being  able  to  help  many 
and  injure  none.  When  judiciously  administered 
in  early  stages  of  the  disease,  tuberculin  seems  to 
control  the  leading  symptoms  of  tuberculosis  such 
as  fever,  cough,  loss  of  weight  and  dyspnoea.  The 
sputa  and  expectorated  bacilli  gradually  diminish 
and  the  disease  loses  its  actively  progressive 
character. 

Hypothyroidism.  The  value  of  opotherapy  may 
be  illustrated  by  .the  use  of  thyroid  extract  in 
cases  where  hypothyroidism  is  a  self-perpetuating 
condition  as  described  above  (cf.  p.  67). 

The  essential  principle  is  thyreo-globulin,  an  iodine- 
containing  substance  which  may  be  extracted  from 
the  follicles  of  the  thyroid  gland  and  used  to  supple- 
ment deficient  thyroid  secretion.  The  drug  is  often 
successful  in  arresting  the  reciprocally  acting  pro- 
cesses ;  indeed  the  treatment  forms  a  notable 
forward  step  in  rational  therapeutics. 

(B)    LOCAL     DISORDERS 

Glaucoma.  Glaucoma  is  a  remarkable  self-per- 
petuating local  disorder.  In  the  words  of  Priestley 
Smith  "  cause  and  effect  react  upon  each  other  in  a 
Vicious  Circle,  and  the  glaucoma  intensifies  itself." 
Nevertheless  the  morbid  process  can  sometimes  be 
arrested  by  the  use  of  such  a  my  otic  drug  as  eserine. 

It  is  especially  in  the  premonitory  stages  and  in 
the  inflammatory  forms  of  glaucoma  that  eserine 
is  of  incontestable  efficiency.  If  on  the  first  indi- 
cations of  an  attack  eserine  is  instilled  into  the  eye 
myosis  shows  itself  in  from  20-40  minutes,  and  all 
the  symptoms  may  be  relieved  without  leaving  a 
trace  behind  them.  As  the  pupil  contracts,  the 


331 


increased  intra-ocular  pressure  subsides,  the  cornea 
becomes  clear,  intra-  and  peri-ocular  pains  vanish, 
visual  acuity  returns.1 

Such  treatment  may  result  in  a  complete  cure 
without  the  necessity  of  surgical  interference.  The 
value  of  the  drug  lies  in  its  power  of  dilating 
Fontana's  spaces  by  causing  the  iris  to  be  stretched 
in  a  radial  direction  and  so  drawn  away  from  the  wall 
of  the  eye-ball.  Filtration  processes  are  thus  pro- 
moted Unhappily,  however,  symptoms  of  glaucoma 
usually  return. 

Nasal  Obstruction.  The  Vicious  Circle  associated 
with  obstructive  hypertrophic  rhinitis  can  sometimes 
be  broken  by  such  a  caustic  as  trichloracetic  acid, 
which  may  be  applied  to  the  turbinal  tissues  so  as  to 
form  linear  scars.  In  a  few  days  the  resulting  cica- 
trices contract  so  that  the  nasal  passages  again  become 
patent.  In  this  way  the  reciprocally  acting  pro- 
cesses are  brought  to  an  end. 

Corns.  Corns  owe  their  persistence  in  large 
degree  to  a  self-perpetuating  factor.  As  often  as 
pressure  is  applied,  the  central  core  irritates  the 
hypertrophied  papillae  of  the  corium,  as  a  result 
of  which  they  are  stimulated  to  increased  prolifera- 
tion. The  more  the  papillae  grow,  the  more  the 
projecting  corn  is  liable  to  pressure  and  vice  versa. 
The  Circle  may  be  arrested  by  the  application  of 
salicylic  acid  which  causes  necrosis  of  the  core  of 
epithelial  cells.  The  entire  corn  is  thus  got  rid  of, 
including  the  hypertrophied  callosity  which  previ- 
ously was  continually  exposed  to  pressure  and 
irritation. 

Scabies.  The  extension  of  scabies  is  largely  the 
result  of  the  itching  and  scratching  caused  by  the 

1  Encyclopedic  Frar^aise  d'Ophtalmologie,  V.,  p.  142. 


332         ItMcious  Circles  in  Dtseaee 

acari,  the  parasite  being  transferred  from  one  part 
of  the  skin  to  another  by  means  of  the  finger-nails. 

This  very  chronic  disorder  may  be  cured  by 
a  variety  of  applications,  of  which  the  popular  and 
best  is  sulphur  ointment  (|MatC  XX.  f).  The  male 
parasite  remains  on  the  surface  of  the  skin  and  is 
readily  destroyed  by  sulphur,  but  the  female  burrows 
under  the  epidermis  so  that  the  epidermal  covering 
of  the  burrows  must  first  of  all  be  softened  by 
soaking  in  hot  water,  and  removed  by  a  rough 
towel.  The  female  parasite  will  then  be  exposed 
and  is  quickly  killed  by  the  ointment. 

If  at  the  same  time  the  clothing  is  disinfected,  the 
circular  reactions  will  be  speedily  broken  and  the 
disease  cured. 

Similar  principles  apply  to  the  treatment  of 
pediculosis. 

Pruritus.  Pruritus  may  be  a  self-perpetuating 
condition  quite  apart  from  the  presence  of  parasites, 
and  occurs  most  frequently  in  connection  with 
certain  parts  of  the  body  such  as  the  anus  or  the 
vulva.  So  intense  may  the  itching  be  that  the 
sufferer  cannot  refrain  from  scratching,  and  this, 
while  giving  temporary  relief,  in  reality  accentuates 
the  trouble.  Frequently  the  scratching  even  pro- 
duces organic  changes  in  the  skin  which  lead  to 
further  pruritus.  Various  local  applications  such  as 
carbolic  acid  or  perchloride  of  mercury  lotions  some- 
times act  like  a  charm  in  arresting  this  obstinate 
disorder.  In  other  cases  a  neurotic  element  is  pre- 
sent which  needs  constitutional  treatment. 

These  few  examples  must  suffice  to  indicate  how 
drugs  may  be  used  to  interrupt  morbid  processes 
that  are  aiding  and  abetting  each  other.  The 
history  of  medicine  shows  that,  in  the  past,  much 
therapeutical  gold  has  been  mixed  with  dross. 
Even  Homer  knew  that  ^ap/xaK-a  iroXXa  ptv  eV0Ad 
,  TroXXa  Se  Xvypa..  "  Many  remedies  in  the 


333 


cup  are  healing,  but  many  are  also  harmful."1  If 
disease  is  studied  from  the  point  of  the  circulus 
vitiosus,  i.e.  both  as  cause  and  as  effect,  drugs  will 
be  prescribed  with  greater  precision  as  to  the  end 
in  view  ;  therapeutics  will  become  more  rational 
and  more  successful. 

III.     SURGICAL   APPLIANCES 

Surgical  appliances  are  frequently  successful  in 
arresting  injurious  circular  reactions  ;  a  few  exam- 
ples will  suffice  to  illustrate  their  utility. 

Mechanical  Supports.  Mechanical  supports  in 
the  shape  of  pads  or  springs  often  relieve  the  self- 
intensifying  conditions  complicating  flat-foot,  a 
disorder  which  as  a  rule  is  primarily  due  to  weakness 
of  the  calf  muscles,  the  tibialis  anticus  and  the  per- 
oneus  longus.  Owing  to  such  weakness  the  plantar 
arch  loses  support  and  subsides,  such  subsidence  be- 
ing aggravated  by  the  stretching  of  the  supporting 
ligaments  and  consequent  valgus  ;  the  greater  the 
stretching  the  more  does  the  arch  subside.  The 
concurrent  subluxation  of  the  tarsus  then  throws 
further  strain  on  the  supporting  tendons  and 
ligaments,  and  so  the  process  steadily  advances. 
At  other  times  flat-foot  may  be  caused  by  some 
minor  traumatic  displacement  of  the  tarsal  or 
metatarsal  bones.  Such  displacement  causes  weak- 
ening of  the  neighbouring  muscles  which  is  soon 
followed  by  their  atrophy  and  by  further  flat-foot. 

Cyriax  writes  : 

"  These  displacements  often  escape  notice  because 
they  are  so  slight  in  amount,  or  if  recognised  are  con- 
sidered to  be  only  a  trivial  secondary  result  of  the 
flat-foot.  Of  course,  in  many  cases  they  are  actually 
secondary,  but  even  then  they  are  of  considerable 

Odyssey,  IV.,  230. 


334  IDicione  Circles  in  Bieease 


importance,  because  they  form  part  of  a  Vicious  Circle, 
and  may  be  aggravating,  or  at  any  rate  preventing 
amelioration  of,  this  condition."1 

Other  sequelae  may  result  from  trie  continual 
aching  and  pain  associated  with  flat-foot,  which 
may  be  so  severe  as  to  curtail  active  exercise.  The 
sufferer  in  consequence  tends  to  put  on  flesh,  thus 
throwing  further  weight  on  the  weakened  arch  and 
perpetuating  the  disorder.  The  weaker  the  arch 
the  greater  the  accumulation  of  fat  and  vice  versa. 
Treatment  depends  on  the  severity  of  the  disorder. 
In  the  early  stages  systematic  exercises  and  massage 
of  the  calf  muscles,  combined  with  periods  of  rest, 
may  suffice  to  effect  a  cure.  But  where  the  mode  of 
life  involves  prolonged  standing  with  little  relief 
by  the  exercise  of  walking,  some  mechanical  support 
is  usually  desirable  which  will  retain  the  arch  in  its 
normal  position,  so  that  the  irritated  joints  may  be 
rested  and  the  muscles  which  have  been  over- 
stretched and  over-loaded  through  the  malposition 
be  relieved  from  strain.  Such  mechanical  supports, 
even  if  only  temporary  expedients,  serve  a  good 
purpose  until  the  primary  weakness  has  been 
corrected  by  means  of  massage  and  improved 
nutrition. 

The  treatment  of  varicose  veins  by  means  of 
elastic  bandages  is  another  example  of  a  process  of 
injurious  reciprocation  being  arrested  by  means  of 
a  mechanical  contrivance  A  well-adjusted  bandage 
supports  the  weakened  vein-walls  and  prevents  fur- 
ther dilatation  as  well  as  valvular  incompetence 

(flMate  XXL  a). 

Other  illustrations  may  be  found  in  the  application 
of  a  truss  for  hernia,  a  belt  for  splanchnoptosis,  a 
jacket  for  spinal  curvature  or  a  pessary  for  uterine 
displacement  (flMate  XXI.  b,  c). 

1  Flat-foot  in  its  Clinical  Aspects,  Clinical  /.,  1918,  p.  140. 


Suraical  appliances 


335 


/y^v 
\{     \ 

It  71 

vv  I  /J 


VARICOSE  VEINS 


(b)  HERNIA 


(c)  PROLAPSE  OF  UTERUS        (d)  PROSTATIC   CONGESTION 


(e)  ACCUMULATION  OF  WAX 


(f)  MYOPIA 


plate  XXI.— She  36reahtnG  of  tbe  Circle 
b£  Suroical  appliances. 


336          Dicioue  Circlce  in  Bteease 

Catheterisation.  Some  circular  reactions  associ- 
ated with  retention  of  urine  which  have  been 
described  in  Chapters  VII.  and  VIII.  are  frequently 
arrested  by  catheterisation.  Where  congestion  has 
led  to  retention  and  retention  to  congestion,  evacu- 
ation of  the  bladder  allows  the  congestion  to  subside 
and  the  sequence  to  be  broken  (fMfltC  XXI.  d).  In 
the  case  of  retroversion  of  the  gravid  uterus,  associ- 
ated with  retention,  evacuation  of  the  bladder  is 
often  followed  by  replacement  of  the  uterus. 

Other  injurious  correlations  are  arrested  by  the 
use  of  the  Eustachian  catheter  in  aural  disease. 

Obstruction  may  be  also  relieved  by  probes  or 
bougies.  Stenoses  of  the  lacrymal  duct,  oesophagus 
or  rectum  are  cases  in  point. 

Hypodermoclysis.  Hypodermoclysis  is  a  method 
of  supplying  fluid  to  the  body,  which  may  be  of 
great  service  in  certain  self-perpetuating  conditions 
associated  writh  shock  or  haemorrhage.  Those  con- 
ditions are  marked  by  a  low  blood-pressure,  with  a 
feebly  acting  heart,  a  depleted  arterial  and  an 
engorged  venous  system,  the  anaemic  vaso-motor 
centre  having  lost  control  of  the  splanchnic  area. 
Saline  injections  of  fluid  may  be  the  means  of  restor- 
ing the  blood-pressure.  The  heart,  which  had 
lost  its  contractility  through  want  of  blood,  regains 
its  systolic  activity  and  is  able  to  pump  a  supply  up 
to  the  vaso-motor  centres.  Thus  one  improvement 
leads  to  another,  until  the  morbid  process  is  arrested  ; 
indeed  the  treatment  is  often  extraordinarily  success- 
ful. Adrenalin  is  sometimes  added  to  the  solution, 
as  referred  to  on  p.  338.  Abdominal  or  rectal 
injections  may  be  used  for  a  similar  purpose. 

Intra- venous  injections  of  hypertonic  saline  solu- 
tions are  also  successful  in  interrupting  the  dangerous 
correlations  that  complicate  cholera.  In  favourable 
cases  such  injections  immediately  introduce  the  stage 
of  reaction  ;  the  circulation  is  invigorated,  the 


Surgical  appliances  337 


diarrhoea  ceases,  the  functional  activity  of  the 
kidneys  returns  ;  the  elimination  of  toxins  is 
re-established.  The  patient  who  appeared  little 
better  than  a  corpse  is  resuscitated. 

Irrigation.  Self-aggravating  conditions  may  be 
arrested  by  irrigation  with  syringes  or  irrigators. 
Illustrations  of  such  methods  may  be  found  in 
cases  of  accumulation  of  wax  in  the  meatus  (JMatC 
XXI.  e),  of  coprostasis,  of  pus  in  the  antrum  or  the 
bladder  and  so  forth. 

The  use  of  the  stomach  tube  in  cases  of  gastrectasis 
is  another  example.  Patients  are  sometimes  met 
with  in  whom  the  dilated  stomach  has  so  sunk  in  the 
abdomen  as  to  form  a  kink  with  the  duodenum. 
This  kink  retards  the  escape  of  food  through  the 
pylorus,  thus  causing  retention  and  further  gastrect- 
asis. If  the  retained  ingest  a  are  washed  out  with 
the  help  of  a  stomach  tube,  the  ptosis  is  relieved  ; 
the  pyloric  kink  is  abolished  and  the  retention  of 
the  ingest  a  ceases. 

Artificial  Lens.  Many  disorders  have  been  refer- 
red to  above  in  connection  with  errors  of  refrac- 
tion, and  can  frequently  be  cured  by  the  use  of 
artificial  lenses.  For  example,  in  progressive  myo- 
pia the  short-sightedness  and  the  elongation  of  the 
eye-ball  react  on  one  another.  The  use  of  concave 
lenses  removes  the  near  point,  relieves  the  undue 
pressure  on  the  globe,  and  checks  the  progress  of 
the  myopia  (gMatC  XXI,  f). 

Again  in  hypermetropia  the  excessive  strain  on  the 
ciliary  muscle  frequently  produces  accommodative 
asthenopia  leading  to  neurasthenia,  headache  and 
insomnia,  cause  and  effect  reacting  on  each  other. 
Here  a  suitable  convex  lens  may  relieve  the  over- 
taxed ciliary  muscle  and  give  relief. 

Rbntgen  Rays.  Rontgen  rays  are  of  great 
value  in  breaking  the  Circles  associated  with 


33$          IDicious  Circles  in  Disease 

trichophytosis  ;  this  treatment  constitutes  a  notable 
advance  in  dermatology. 

Hitherto  the  fungus  in  its  retreat  at  the  bottom 
of  the  hair  follicles  has  proved  inaccessible  to  attack 
since  no  parasiticides  could  reach  it,  while  every 
attempt  at  epilation,  owing  to  the  brittleness  of  the 
diseased  hair,  left  in  the  follicle  a  fragment  which 
sufficed  to  perpetuate  the  disease.  Fortunately 
X-rays  exert  an  extraordinary  depilatory  effect,  as  a 
result  of  which  the  entire  hair  in  spite  of  its  brittle- 
ness  is  thrown  off.  So  successful  and  reliable  is  this 
method  of  treatment  that  a  single  application  of  an 
adequate  dose  of  X-rays  for  about  fifteen  minutes 
will  usually  cure  a  patch  of  ringworm.  A  few 
days  after  treatment  all  the  hair,  both  healthy  and 
diseased,  on  the  area  exposed  to  the  rays  is  shed, 
and  as  soon  as  the  last  diseased  hair  has  fallen  out, 
the  infection  is  at  an  end.  In  at  most  twenty-five 
days  after  the  application  of  the  rays  the  disease 
ought  to  be  cured. 

Amongst  other  appliances  that  are  used  for 
arresting  circular  reactions  may  be  mentioned 
electrical  batteries  for  cases  of  paralysis,  tourniquets 
for  cases  of  aneurysm,  and  cauteries  for  neoplasms. 

IV.    SURGICAL   OPERATIONS 

Some  Circles  can  only  be  broken  by  the  knife  of 
the  surgeon.  At  such  times: — ov  77/305  larpov  <ro(j>ov 
Vpijvtlv  cVojSas  7T/30S  To/xaWi  Tn^arj,  "  Skilful  leach 
mutters  no  spell  o'er  sore  that  needs  the  knife."1 

The  following  classification  of  operations  adapted 
to  this  purpose  will  be  found  convenient  : 
I.     Organectomy 
II.     Organopexy 
III.     Organoplasty 

'Sophocles,  Ajax  581. 


Surgical  ©perattone  339 

IV.  Lithotomy 

V.  Stricturotomy 

VI.  Tenotomy 

VII.  Osteotomy 

VIII.  Decompression 

IX.  Removal  of  Neoplasms 

X.  legation  of  Vessels 

XI.  Drainage 

I.     ORGANECTOMY 

The  total  removal  of  an  organ  is  sometimes 
required  for  the  arrest  of  a  pernicious  circular 
reaction.  Appendicectomy  and  hysterectomy  will 
serve  as  examples. 

Appendicectomy.  Appendicitis  usually  arises 
from  some  inflammatory  condition  which  narrows 
the  appendicular  duct  and  causes  a  retention  of 
secretions.  Such  retention  in  its  turn  aggravates 
both  inflammation  and  obstruction,  and  eventually 
a  closed  septic  cavity  results,  involving  serious 
illness  and  even  danger  to  life.  Such  an  injurious 
sequence  may  be  arrested  by  appendicectomy  ((Mate 
XXII.  a). 

Hysterectomy.  Another  operation  with  a  similar 
result  is  the  removal  of  a  bulky,  inflamed  and 
procident  uterus  which  is  mechanically  interfering 
with  the  uterine  circulation  and  so  contributing  to 
its  own  enlargement.  The  procidence  is  then  both 
cause  and  effect  of  congestion,  and  often  can  only 
be  effectively  remedied  by  hysterectomy. 

Amongst  other  examples  of  organectomy  that 
break  the  Circle  are  splenectomy  for  haemolytic 
jaundice,1  cholecystectomy  for  cholelithiasis,  excision 

1  Lancet,  1916,  II.,  p.  889. 


34Q          iDidous  Circles  in 


of  the  lachrymal  sac  for  dacryocystitis,1  prostatect- 
tomy  for  prostatic  retention  and  colectomy  for 
intestinal  stasis. 

II.     ORGANOPEXY 

Various  organs  are  liable  to  undergo  displace- 
ment, and  such  displacement  aggravates  the  primary 
disorder. 

Gastropexy.  An  enlarged  and  loaded  stomach 
sometimes  sinks  in  the  abdomen  and  pulls  down 
the  first  section  of  the  duodenum.  Hence  results 
a  kink  which  hinders  the  escape  of  the  gastric 
contents  and  provokes  further  gastroptosis.  The 
more  extensive  the  ptosis  the  greater  the  kink  and 
the  more  obstinate  the  stasis.  Such  a  displacement 
may  be  cured  by  means  of  gastropexy  which  restores 
the  stomach  to  its  natural  position  and  retains  it 
there,  either  by  suturing  the  organ  to  the  abdominal 
parietes  or  by  shortening  and  strengthening  the 
natural  supporting  ligaments.  In  successful  cases 
the  self-aggravating  process  is  arrested  and  followed 
by  recovery. 

Hysteropexy.  Hysteropexy  is  sometimes  re- 
sorted to  for  the  relief  of  procidentia  uteri.  This 
displacement  may  be  due  either  to  an  increase  of  the 
forces  that  tend  to  depress  the  uterus,  or  to  weak- 
ening of  its  supports,  or  to  both  factors  operating 
simultaneously.  In  many  cases  an  abnormally 
bulky  and  heavy  uterus,  on  the  one  hand,  and  a 
ruptured  or  weakened  perinaeum,  on  the  other,  are 
both  present.  The  weaker  the  perinaeum  the  further 
the  uterus  descends  ;  the  further  the  uterus  descends 
the  weaker  grows  the  perinaeum.  Moreover  the 
prolapsed  organs  become  congested  and  this  con- 
gestion intensifies  the  prolapse. 

1  British  Med.  /.,  1907,  I.,  p.  420. 


Surgical  Operations 


341 


(a)  ORQANECTOMY 


(b)  ORGANOPEXY 


(c)  ORQANOPLASTY 


(d)  LITHOTOMY 


(e)  SPRICTUROTOMY 


(f)   DECOMPRESSION 


plate  XXII.— She  Breaking  of  the  Circle 
b^  Surgical  Operation. 


342  Dlctous  Circles  in 


In  severe  cases  neither  pessary,  tampon  nor 
bandage  retain  the  displaced  organ,  and  some 
operation  is  called  for.  By  the  strengthening  or 
shortening  of  the  uterine  supports  the  reciprocating 
process  may  be  checked  and  the  disorder  cured 

(plate  xxii.  b). 

Colopexy,  hepatopexy  and  nephropexy  are  other 
operations  with  a  more  or  less  similar  purpose. 

III.     ORGANOPIyASTY 

Under  the  title  organoplasty  may  be  grouped  a 
series  of  operations  devised  in  order  to  interrupt 
injurious  correlations. 

Enteroplasty.  Intestinal  obstruction  creates 
various  such  conditions.  There  may  be  coprostasis, 
toxaemia,  meteorism,  intestinal  paralysis  and  aggra- 
vated stasis  ;  coprostasis,  kinking  of  the  gut  and 
aggravated  stasis  ;  intussusception,  increased  peri- 
stalsis, aggravation  of  intussusception  ;  strangu- 
lation of  a  hernia,  vomiting,  aggravated  strangulation; 
enteroptosis,  obstruction,  aggravated  ptosis.  Many 
of  these  disorders  are  curable  by  drugs.  But  in 
neglected  cases  where  gangrene  threatens  or  has 
supervened,  enteroplasty  is  often  required.  The 
injured  segment  is  removed,  and  the  two  ends  of 
healthy  gut  are  joined  end  to  end  or  anastomosed 
side  to  side  (plate  XXII.  c). 

Gastroplasty.  Gastroplasty  may  be  called  for 
in  the  case  of  gastric  ulcers  when  complicated  with 
hyperchlorhydria,  pyloric  spasm  and  retention  of 
the  gastric  contents.  This  concatenation  of  pheno- 
mena acting  and  reacting  on  each  other  leads  to  a 
grave  condition  of  anaemia,  malnutrition  and  weak- 
ness. Various  operations  have  been  devised  for  its 
relief,  including  partial  resection  of  the  stomach  and 


Surgical  Operations  343 

gastro-jejunostomy.  By  either  of  these  operations 
the  stagnation  of  the  gastric  contents  may  be 
prevented  ;  the  hyperchlorhydria  is  arrested  and 
the  spasm  of  the  pylorus  subsides.  Pain  ceases, 
appetite  returns  and  the  patient  regains  the  weight 
and  strength  that  had  been  lost. 

Thyroplasty.  Partial  resection  of  the  thyroid 
sometimes  breaks  a  dangerous  complication  which 
may  arise  when  the  hypertrophied  gland  compresses 
the  trachea  and  narrows  its  lumen,  or  by  pressure 
on  nerves  excites  a  reflex  respiratory  spasm.  Acute 
dyspnoea  may  then  result  from  any  exertion  that 
calls  the  supplementary  respiratory  muscles  into 
action,  since  these  muscles,  in  contracting,  press  the 
goitre  against  the  trachea,  further  diminish  the 
lumen  and  thus  increase  the  dyspnoea  ;  at  times  the 
glottis  may  be  closed  by  spasm.  Unless  promptly 
relieved  by  operation,  the  victim  dies  self-garotted. 

Blepharoplasty  is  another  operation  which  breaks 
the  correlations  associated  with  entropion  and 
ectropion  of  the  eye-lids. 

IV.     LITHOTOMY 

Lithiasis  includes  various  disorders  associated  with 
the  formation  and  growth  of  concretions  in  the 
tubes  and  cavities  of  the  body.  Such  concretions 
gradually  enlarge  as  a  result  of  interesting  circular 
reactions  which  have  been  described  in  former 
Chapters  and  need  not  be  repeated  here. 

Lithotomy.  By  the  operation  of  lithotomy  or 
litholapaxy  the  surgeon  interrupts  these  reactions. 
With  the  removal  of  the  calculus  the  irritation 
ceases  ;  the  excessive  deposition  of  salts  and 
the  increased  production  of  mucus  are  arrested  ; 
the  self -perpetuating  conditions  are  brought  to  an  end 

(plate  XXH.  d). 


344          IDicious  Circles  in  Disease 


V.     STRICTUROTOMY 

Various  channels  of  the  body  are  subject  to 
stricture,  a  self-aggravating  disorder  which  fre- 
quently calls  for  surgical  aid. 

Herniotomy.  A  striking  example  is  met 
with  when  a  coil  of  intestine  is  strangled  in  a  hernia 
or  a  volvulus.  The  intestinal  walls  become  acutely 
congested  through  constriction  of  the  blood-vessels, 
while  the  lumen  is  distended  with  blood  and  gas, 
such  congestion  and  distension  in  turn  intensifying 
the  strangulation.  Frequently  the  tension  causes 
more  gut  and  mesentery  to  be  drawn  within  the 
constricting  ring,  to  become  congested  and  strangled 
in  their  turn.  By  the  operation  of  laparotomy  or 
herniotomy  the  constriction  may  be  relieved  and 
the  circulation  restored  (JMatC  XXII.  e). 

Urethrotomy.  Another  illustration  is  presented 
by  stricture  of  the  urethra  associated  with  severe 
straining,  hyperaemia  of  the  mucous  membrane  and 
aggravation  of  the  stricture.  The  difficulty  of 
micturition  may  be  so  great  as  to  call  for  urethro- 
tomy,  which  cures  the  trouble. 

Allied  to  these  conditions  are  various  other 
forms  of  strangulation,  e.g.  paraphimosis,  con- 
striction of  the  prolapsed  cervix  uteri  by  the  vulvar 
folds,  nipping  of  prolapsed  haemorrhoids,  narrowing 
of  the  trachea  by  hypertrophied  thyroid  etc.  In  all 
these  cases  operative  measures  arrest  the  morbid 
process. 

VI.     TENOTOMY 

Orthopaedic  disorders  are  frequently  complicated 
by  injurious  circular  reactions  which  may  be  arrested 
by  tenotomy. 

For  example,  various  forms  of  clubfoot  are  met 
with  in  which  adaptive  shortening  of  the  muscles 
and  ligaments  has  led  to  displacement  of  bones  and 


Surgical  ©perattone  345 

fixation  in  an  abnormal  position.  Such  displace- 
ment, on  the  principle  that  performance  of  function 
in  a  wrong  position  leads  to  deformity,  produces 
further  distortion  and  shortening,  and  so  the  process 
aggravates  itself.  Nature,  as  has  been  said,  cannot 
cure  clubfoot  ;  it  can  only  render  the  condition 
worse.  With  the  help  of  tenotomy  the  displaced 
bones  may  be  brought  back  to  their  normal  position 
and  the  overstretched  and  weakened  muscles  restored 
to  functional  activity. 

Another  illustration  is  afforded  by  acute  anterior 
poliomyelitis.  In  the  later  stages  of  this  disease 
recovery  is  checked  by  the  vigorous  contracture  of 
healthy  opponent  muscles.  When  these  have  been 
divided  by  tenotomy,  natural  contractions  of  the 
paralysed  muscles,  even  though  feeble,  again  become 
possible  and  react  beneficially  on  the  central  lesion. 
The  resulting  improvement  in  its  turn  promotes 
further  muscular  action. 

VII.     OSTEOTOMY 

Osteotomy  is  resorted  to  for  the  arrest  of  various 
circuli  vitiosi. 

Genu  valgum  or  knock-knee  frequently  starts 
with  a  rickety  bending  of  the  femur  or  with  some 
subsidence  of  the  plantar  arch,  as  a  result  of  which 
the  two  tibial  tuberosities  no  longer  receive  an  equal 
weight  from  the  femoral  condyles,  the  outer  tuber- 
osity  receiving  more  than  its  due  share.  This 
extra  pressure  exerted  by  the  external  condyle 
retards  the  growth  of  the  femoral  epiphysis  extern- 
ally, while  the  growth  of  the  inner  condyle  is  stimu- 
lated by  the  diminished  pressure  received.  More- 
over when  once  the  knee-joint  is  no  longer  at  right 
angles  to  the  axis  of  the  limb  the  internal  lateral 
ligament  is  placed  at  a  disadvantage  and  stretches. 
This  involves  weakness  and  further  mischief.  Hence, 
when  once  started,  this  self-aggravating  deformity 


346          IDictoue  Circles  in  Disease 

makes  steady  progress,  since  the  more  the  knee 
yields  the  greater  is  the  difference  in  the  pressure  on 
the  two  tuberosities  and  the  greater  are  the  resulting 
changes. 

By  means  of  osteotomy  the  unequal  level  of  the 
condyles  is  corrected,  and  the  limb  restored  to  the 
straight  position.  Knock-knee  and  flat-foot  are 
often  simultaneously  present,  each  contributing  to 
the  other. 

Osteotomy  may  also  be  called  for  in  the  severe 
forms  of  flat-foot,  a  self-perpetuating  disorder  which 
has  already  been  discussed  on  p.  333.  In  minor 
degrees  of  this  disorder  massage,  exercises  and 
supporting  pads  suffice.  But  where  the  arch  has 
entirely  collapsed,  tarsectomy  may  be  required  for 
the  purpose  of  restoring  the  arch  and  strengthening 
it  by  means  of  bony  ankylosis.  The  most  widely 
practised  is  probably  Ogston's  method  of  denuding 
the  cartilaginous  surfaces  of  the  astragalo-scaphoid 
joint,  and  immobilising  the  two  bones  with  ivory 
pegs.  There  are  various  modifications,  all  aiming 
at  arresting  the  self -intensify  ing  deformity. 

Hallux  valgus  is  sometimes  cured  by  means  of 
osteotomy.  In  this  malformation  the  first  phalanx 
deserts  the  inner  aspect  of  the  metatarsal  bone  and 
slips  round  towards  its  outer  aspect.  As  a  result  of 
this  displacement  the  extensor  proprius  pollicis, 
going  straight  to  its  insertion,  lies  towards  the  outer 
side  of  the  metatarso-phalangeal  joint  and  thus 
acquires  increased  power  of  aggravating  the  deform- 
ity. The  greater  the  displacement  the  more  injuri- 
ous the  muscular  action.  By  means  of  osteotomy 
ankylosis  of  the  metatarso-phalangeal  joint  may  be 
brought  about  and  the  disorder  arrested. 

Extreme  rickety  curvature  of  the  legs  affords 
another  example  of  a  progressive  lesion  which  may 
be  relieved  by  osteotomy. 


Surgical  0perationg  347 

VIII.     DECOMPRESSION 

Increased  pressure  in  the  cranial  and  other 
cavities  of  the  body  may  be  a  self-perpetuating 
disorder  involving  grave  danger  to  life. 

Trephining.  A  striking  illustration  occurs  in 
ingravescent  apoplexy  as  has  been  fully  described 
on  p.  29.  When  the  haemorrhage  is  copious,  as 
frequently  happens  if  the  middle  meningeal  artery 
is  ruptured,  the  patient  usually  succumbs  to  cerebral 
compression  and  arrest  of  respiration,  if  Nature 
is  left  to  her  own  resources.  The  circulus  vitiosus 
becomes  a  circulus  necator.  By  the  operation  of 
trephining,  however,  the  effused  blood  may  be 
removed.  The  cerebral  anaemia  is  relieved  ;  the 
blood-pressure  falls  ;  the  coma  subsides.  The  vari- 
ous bodily  functions  may  almost  instantly  be 
resumed  as  a  result  of  this  operation  (plate  XXII,  f). 

Iridcctomy.  Decompression  is  frequently  re- 
quired in  the  case  of  glaucoma,  a  striking  example  of 
a  self -intensifying  disorder,  as  has  been  described  on 
p.  175.  Apart  from  operative  interference  irremedi- 
able blindness  is  not  uncommon,  while  the  eye  may 
remain  a  source  of  severe  and  recurrent  pain,  involv- 
ing loss  of  sleep  and  impaired  health.  Happily 
the  injurious  sequence  may  be  arrested  by  a  success- 
ful iridectomy.  Still  better  is  an  operation  which 
creates  a  filtering  cicatrix,  such  as  a  combined 
iridectomy  and  sclerectomy,  or  a  corneo-scleral 
trephining.  The  increased  intra-ocular  pressure  is 
relieved,  the  displaced  lens  and  iris  return  to  their 
normal  position,  and  the  self-regulating  mechanism 
governing  secretion  and  excretion  again  comes  into 
operation. 

Venesection.  The  relief  of  excessive  blood-pres- 
sure may  also  be  effected  by  venesection  which  may 
prove  a  life-saving  operation  in  some  cases  of  failing 


348  IDicious  Circles  in  3Di0ea0e 


heart  associated  with  over-repletion  and  dilatation. 
As  a  result  of  the  heart  failure  the  medullary  centres 
are  insufficiently  supplied  with  blood,  and  in  response 
induce  a  general  vaso-constriction  which  forces 
blood  to  the  anaemic  centres,  thus  imposing  an 
extra  burden  on  the  already  over-taxed  heart. 
The  cardiac  failure  and  bulbar  anaemia  act  and  react 
on  each  other.  Phlebotomy  may  under  such  circum- 
stances give  immediate  relief  ;  the  pressure  falls, 
the  cardiac  dilatation  diminishes,  the  systole  increases 
in  force,  the  viscosity  of  blood  lessens,  the  dyspnoea 
subsides,  the  cyanosis  is  reduced. 

Amongst  other  self-intensifying  conditions  which 
may  be  relieved  by  decompression  are  hydrocephalus, 
cerebro-spinal  meningitis  and  otitis  media. 

IX.     REMOVAL  OF   NEOPLASMS 

Many  neoplasms  owe  their  growth  to  reciprocally 
acting  sequences  which  call  for  surgical  aid  ;  a 
familiar  illustration  is  presented  by  adenoids,  a 
disorder  which  is  closely  related  aetiologically  with 
chronic  catarrh  of  the  nase-pharynx,  and  in  its  turn 
perpetuates  such  catarrh. 

As  a  result  of  this  morbid  process  adenoids  may 
grow  so  large  as  to  block  the  posterior  nares,  in- 
volving mouth-breathing  and  other  concomitant 
evils.  Their  removal  interrupts  the  injurious  se- 
quence and  exerts  a  beneficial  influence  on  physical 
and  mental  health. 

Polypi,  again,  frequently  originate  in  a  chronic 
catarrh,  which  leads  to  the  formation  of  a  neoplasm 
which  in  its  turn  perpetuates  the  catarrh.  In  other 
cases  new  growths  may  give  rise  to  a  Circle  by 
causing  mechanical  obstruction.  This  not  uncom- 
monly occurs  in  the  intestines,  as  pointed  out  by 
Hook  and  Kanaval  : 

"  Strictures  and  growths,  by  a  partial   retention  of 
faeces,  develop  a  Vicious  Circle  of  impaired    function 


Surgical  ©perattone  349 

and  partial  stasis  that  may  end  in  complete  stasis   at 
any  time."1 

Removal    of   the    polypus    or    new   growth    brings 
relief. 

Amongst  other  examples  may  be  mentioned 
enlarged  tonsils,  and  polypi  of  the  nose,  middle 
ear  and  other  regions. 

X.     IvIGATION  OF  VESSEL 

Diseases  of  the  arteries  and  veins,  including 
aneurysms  and  varices,  are  often  self-perpetuating 
conditions. 

Aneurysm  is  usually  caused  either  by  weakening 
of  the  arterial  coats,  or  by  strain  resulting  from  a 
rise  of  blood-pressure.  The  more  the  arterial  walls 
yield  the  greater  the  tension  to  which  they  are 
subjected  ;  the  greater  the  tension  the  thinner  and 
weaker  do  they  become.  Thus  the  dilatation  be- 
comes progressive  (cf.  p.  57). 

In  the  case  of  varicose  veins  dilatation  and 
increased  tension  also  aggravate  each  other.  In- 
competence of  the  valves  is  a  further  contributing 
factor. 

By  ligaturing  the  affected  arteries  or  veins  the 
surgeon  arrests  these  reciprocations.  The  tying  of 
piles  supplies  another  illustration. 

XI.     DRAINAGE 

Various  circular  reactions  are  established  by  the 
accumulation  of  morbid  fluids  in  the  cavities  and 
tissues  of  the  body,  e.g.  effusions  associated  with 
pleurisy,  pericarditis  or  ascites,  abscesses  and  cerebro- 
spinal  meningitis.  The  process  of  the  accumulation 
varies  somewhat  in  different  cases  and  has  been 
described  in  previous  Chapters.  The  surgeon  is  often 
called  in  to  deal  with  the  morbid  processes  at  work. 


Keen,  Surgery,  IV.,  p.  654. 


350  IDicioua  Circles  in  2>isea$e 

Paracentesis.  The  operation  of  paracentesis 
is  frequently  resorted  to  in  order  to  remove  accumu- 
lations of  fluid  in  the  pleura,  pericardium  and 
peritoneum. 

Sajous  thus  refers  to  paracentesis  of  the  pleura, 
which  may  serve  as  a  type  of  other  operations  : 
"  Tapping  may  reverse  the  Vicious  Circle  into  a 
beneficial  Circle,  viz.  one  in  which  the  possibility  of 
respiratory  movement,  and  hence  of  the  pumping 
action,  having  been  restored,  absorption  has  begun  or 
increased  in  consequence.  The  greater  the  absorption, 
the  greater  the  respiratory  movement  and  vice  versa. 
The  beneficial  Circle  thus  established  will  tend,  appar- 
ently, to  accelerate  the  rate  of  absorption  beyond  what 
it  would  otherwise  have  been.  The  fact  that  often 
the  withdrawal  of  only  a  small  quantity  of  a  large 
effusion  is  followed  by  rapid  absorption  of  the  remainder 
might  be  accounted  for  in  this  way.  The  underlying 
absorptive  power  might  not  have  improved  sufficiently 
to  permit  of  actual  resorption,  yet  have  improved 
sufficiently  for  resorption  when  aided  by  the  respiratory 
movement  restored  by  partial  removal  of  the  effusion."1 

Opening  of  Abscess.  Under  the  same  heading 
may  be  placed  the  drainage  of  inflammatory  swel- 
lings or  abscesses  which  are  complicated  by  self- 
perpetuating  conditions.  These  have  been  fully 
described  on  p.  60. 

When  an  abscess  is  drained,  a  multitude  of  pyogenic 
bacteria  and  their  chemical  products  are  got  rid  of. 
Many  beneficent  phagocytes  and  enzymes  are  lost 
at  the  same  time,  but  these  are  rapidly  replaced,  so 
that  the  ultimate  gain  far  outweighs  the  loss,  and 
the  processes  of  repair  are  vastly  strengthened. 
Thus  is  justified  the  old  surgical  aphorism  ubi  pus 
ibi  evacua. 

The  presence    of    special    microbes    may    evoke 

lNew  York  Medical  /.,  1918,  II.,  p.  519. 


Surgical  ©peratkme  351 

other  correlations.  For  example,  bacillus  aerogenes 
capsulatus  (bacillus  perfringens)  grows  rapidly  in  a 
blood  clot,  and  produces  considerable  quantities  of 
lactic  acid  which  in  its  turn  checks  the  emigration 
of  leucocytes  and  thus  facilitates  the  rapid  proli- 
feration of  the  bacilli. 

Fleming  writes  : 

"  When  the  bacillus  aerogenes  capsulatus  grows  on 
blood  it  produces  a  considerable  amount  of  lactic  acid, 
and  it  has  been  shewn  that  lactic  acid  has  a  very  potent 
action  on  leucocytes,  preventing  their  emigration. 
Thus  we  have  a  Vicious  Circle  ;  the  greater  the  growth 
of  the  bacillus  the  more  is  the  production  of  lactic  acid 
and  consequently  the  less  is  the  leucocytic  emigration. 
Unless  such  a  Vicious  Circle  can  be  broken  the  result 
is  likely  to  be  disastrous."1 

Such  a  complication  merely  emphasises  the  value 
of  modern  methods  of  wound  treatment  having  in 
view  the  arrest  of  the  morbid  processes  at  work. 

These  few  illustrations  of  the  applications  of 
surgery  to  the  breaking  of  Vicious  Circles  must 
be  looked  upon  as  suggestive  rather  than  as  com- 
prehensive. Further  illustrations  will  occur  in  the 
practice  of  every  busy  surgeon. 

Many  of  the  disorders  referred  to  are  of  the  gravest 
importance  and  threaten  early  death  unless  relief 
is  forthcoming.  In  the  face  of  such  emergencies 
natura  medicatrix  is  usually  helpless  ;  nor  are  the 
pills  and  potions  of  the  physician  of  much  avail. 
Happily,  however,  as  Hipprocrates  said  centuries 
ago  : 

cO/cocra  </>a/3/na/ca  OVK  i^rat,  crioij/jos  ITJTCU. 
"  What  drugs  will  not  cure,  steel  cures."2 


1  Lancet,  1915,  II.,  p.  37».     Cf.  also  British  Med.  /.,  1917, 

I.,  p.  728  ;    1918,  L,  p.  369- 

2  Aphorisms,  viii.,  6. 


352  Dictous  Circles  in  Disease 


All  honour  to  the  surgeon  whose  art  can  break 
the  Circle  at  the  locus  minoris  resistentice  \  Without 
such  aid  it  would  be  true  of  many  sufferers  to  say : 
pax  illis  cum  morte  solum. 


The  more  important  methods  of  breaking  Vicious 
Circles  have  now  been  briefly  discussed,  although 
the  subject  is  far  from  exhausted.1  Indeed  as 
Vicious  Circles  are  closely  interwoven,  in  warp  and 
woof,  with  the  processes  of  disease,  so  is  their  arrest 
intimately  concerned  with  therapeutics.  Enough, 
however,  has  been  said  to  indicate  to  the  experienced 
physician  how  his  treatment  may  be  adapted  to  the 
particular  problem  with  which  he  is  confronted. 


Psychotherapy  is  often  a  valuable  means  of  breaking  the 
Circle,  and  is  discussed  in  "  The  Vicious  Circles  of 
Neurasthenia  and  their  Treatment,"  by  J.  B.  H. 
Cf.  also  Haydn  Brown,  "Advanced  Suggestion," 
passim.  Massage,  balneotherapy,  electricity,  phy- 
sical exercises  may  also  render  service  under  suitable 
circumstances. 


Chapter 


Conclusion1 


E  have  now  completed  our  survey  of  the 
operations  of  Vicious  Circles  in  animal 
and  vegetable  pathology,  and  pointed 
out  that  this  morbid  process  falls  into 
line  with  other  great  biological  laws  to 
which  all  higher  animals  and  plants  are  subject. 
The  specialisation  of  structure  and  function  associ- 
ated with  evolution  brings  unquestioned  benefits 
in  its  train,  since  specialisation  allows  a  greater 
efficiency  in  the  performance  of  functions.  At  the 
same  time  it  involves  a  liability  to  injurious  cir- 
cular reactions,  when  once  processes  of  disease  have 
been  initiated. 

It  is  strange  that  so  little  attention  has  hitherto 
been  directed  to  this  self -perpetuating  process. 
Primary  reactions  are  the  common-places  of  text- 
books of  animal  and  vegetable  pathology  ;  but  the 
reciprocal  effects  of  those  reactions  on  the  primary 
disorder  are  scarcely  thought  worthy  of  consideration, 
and  yet  such  effects  are  of  far-reaching  influence  on 
the  natural  history  of  disease.  Only  too  often  does 
each  gyration  deepen  the  groove,  so  that  a  restor- 
ation to  normal  conditions  becomes  more  and  more 
difficult. 


^he  following  Journals  contain  articles  by  the  Author 
dealing  with  Vicious  Circles  in  disease  -.—Lancet, 
1887,  I.  ;  1908,  II.  ;  1910,  I.  ;  1912,  I.  British 
Med.  /.,  1907,  I.  ;  1910,  II.  ;  1911,  II.  ;  1913,  I-  ; 
1914,  I.  Practitioner,  1910,  I.  ;  1910,  II.  ;  1912, 
I. ;  1914,  I.  ;  1915,  II. ;  1916,  I. ;  1917,  II-  i 
1918,  II.  Clinical  /.,  1915,  I-  ;  I9l8>  L  J  J9i9»  L 
St.  Bartholomew's  Hospital  /.,  1913,  I-  Medical 
Press,  1910,  II.  British  J.  of  Inebriety,  1915,  II. 
Royal  Horticultural  Society  /.,  1919,  Feb.  Veterinary 
News,  1918,  I. 

353 


354          IDicious  Circles  in  2>iaea$e 

This  subject  of  injurious  circular  reactions  should 
appeal  to  workers  in  several  departments  of  science. 
The  biologist  in  the  widest  sense  of  that  word  will 
find  fresh  light  thrown  on  the  great  principle  of 
correlation  which  plays  so  important  a  role  in  the 
mechanism  of  life.  There  is  a  wide  field  for  research 
into  the  reciprocal  influences  exerted  on  one  another 
by  vital  processes. 

The  zoo-pathologist  and  phyto-pathologist  are 
still  more  closely  concerned  with  Vicious  Circles, 
since  these  exert  a  potent  influence  on  the  phenomena 
which  come  under  their  daily  observation.  Their 
therapeutics  are  largely  concerned  in  interrupting 
the  concatenation  of  morbific  factors. 

The  central  purpose  of  this  Volume,  however, 
is  the  narrower  one  of  assisting  the  physician  in  his 
efforts  to  cure  disease  in  man  ;  only  to  this  aspect 
of  therapeutics  is  any  detailed  attention  given. 
No  disease  of  lower  animal  or  plant  concerns  us  so 
closely  as  does  disease  of  our  own  flesh  and  blood. 
Moreover  organic  evolution  reaches  its  highest 
development  in  the  human  species,  especially  as 
regards  psychical  activities.  On  the  other  hand 
psycho-physical  inter-dependences  render  man 
liable  to  injurious  and  complex  reciprocations  to  a 
degree  that  is  unparalleled  amongst  less  organised 
animals  and  plants. 

The  study  of  Vicious  Circles  exerts  a  fundamental 
influence  on  the  outlook  of  pathology.  It  serves 
as  a  constant  reminder  that  diseases,  far  from  being 
entities,  as  our  ancestors  supposed,  are  due  to  ever- 
acting  morbid  processes  in  which  numerous  organs 
and  their  functions  are  closely  concerned. 

Happily  too  the  subject  is  not  merely  of  academic 
interest  ;  there  is  profit  both  as  regards  diagnosis, 
prognosis  and  treatment.  By  promoting  a  deeper 
insight  into  the  complex  processes  of  disease  a 
familiarity  with  these  Circles  renders  therapeutics 
more  philosophical  and  more  successful. 


Jnbey 


An  *  indicates  that  the  disorder  is  illustrated. 


P««e 

Abductor  paralysis        203*,  206 
Abortion     ..          ..          ..     151 

Abscess,  formation  of        32,  60, 

252,  350 
,,          opening  of          . .     350 

Acapnia 281 

Acari,  infection  with    225,  239*, 

253,  332 

Accoutumance       ..          ..      285 
Achorion  schonleinii         . .     254 
Acid,  hydrochloric  . .     326 

,,     salicylic        . .          . .     331 

„     trichloracetic  . .     331 

Acne  . .          ..        231,  284 

„   cheloid  . .          . .     232 

„  rosacea          . .          . .     231 

Adam-Stokes  syndrome   . .       39 

Adami,  J.  G.          . .        26f,  122, 

165,  195 

Adenoids        192,   194,  312,  348 
Adiposity,  cf.  Obesity 
Adrenalin  .  .  318,  320,  336 

Aerophagy  ..         98f,  247 

.dEtiological  therapeutics         302 
/Etiology  of  Vicious  Circles        i, 
255 

Alae  nasi 194 

Albuminuria          . .          .  •     285 
Alcoholism  160,  279*,  28lf 

Alkaloids,  poisonous         ..      118 
Allbutt,  C.  6,  15,  42,  64,  93,  321 

Allen,  F.  M 167 

Amenorrhcea         . .          .  •      MS 


Ammonia  . .          . .          . .     323 

Amyl  nitrite  . .          . .     321 

Anaemia       32,  37*,  62,  63,  80, 

157,  249,  275,  287,  292,  322 

,,     bulbar        n*,  27,  30,  43, 

267*,  274,  348 

,,     pernicious    . .          . .        63 

Anaesthetic,  danger  of      26,  286 
,,  Nature's        . .    273f 

Anasarca 158 

Anderson,  M.         . .          . .     219 

Andre-Thomas      . .          . .        18 

Aneurysm    51,  55,  57,  241,  271, 
349 

Angina  pectoris  45,  53f,  268,  321 
Anhidrosis . .          . .          . .     233 

Anhydraemia         . .  63,  64 

Animals,  diseases  in  the 

lower  . .      237,  239* 

,,        Vicious  Circles  in    xix., 

3,  4!,  15,  237f,  239*,  353 

Anisometropia       . .          . .     186 

Ankylostoma  duodenale  . .       99 
Anorexia    n*,   16,  24,  308,  324 
Anti-diphtheritic  serum  . .     329 
Anti-peristalsis      . .          . .      I  oo 

Anuria       ..          ..          64,  124 

Anus,  fissure  of     . .          ..     115 

,,      prolapse  at  . .    nsf 

,,      pruritus  of    116,  235,  328 

,      spasm  of  . .    nsf 

Anxiety  neuroses  ..      I2f 

Aortic  regurgitation      37*,  46f, 
293*,  296 


355 


356 


IDicious  Circles  in  SHsease 


Page 
Aortic  stenosis      . .  . .      269 

,,        valve,  rupture  of  46,  269 
Apnoea        . .          . .          . .     272 

Apoplexy      11*,  29f,   121,  zyji, 
267*,  275,   347 
Appel  on  lowered 
resistance 


Appendicectomy 
Appendicitis 
Appetite,  loss  of 


•  •      255 

•  •     339 
89*,  logf 

ii*,  1 6,  308, 
324 

,,  perversion  of    99,  160, 

323 

,,  suppression  of  24,  295 
Appliances,  surgical  333f,  335* 
Arrhythmia  . .  38,  54 

Art,  breaking  of  Circles  by  3011, 
307*,  315*,  335*,  341* 
Arterio-sclerosis  . .  56f,  156 
Artificial  Circles  215,  2771,  279* 
Aryteno-epiglottidean 

oedema  . .          . .     201 

Ascarides    . .  .  .          99,   100 

Ascites  113,   125,  311,  320,  349 

Asclepiades  . .          . .     xix. 

Aspergillus  niger  . .        210,  228 

Asphyxia  50,  80,  81,  202, 

204,  209,  267* 

,,        neonatorum  152,  272, 

273 

Asthenopia  173*,  186,  187,  294, 
337 

Asthma      ..  73*,  851,  324 

Astigmatism  ..  ..  187 
Asystolie  hepatique  . .  41 

Atelectasis  .  .  78,   155*,  272 

Athens,  race  to  . .  . .  266 
Atony  of  bladder  . .  . .  133 
Atrophy  of  muscles  . .  34 

Aural  Circles          . .     2iof,  213* 
,,      neuroses      . .          . .     .216 
„      polypus        ..        214,  348 
Auricular  fibrillation        38,  319 


Page 

Auto-infection         75,   100,   116, 
225,  328 

,,   -inoculation     72,  211,  228 
Autolysis    . .          . .          . .      104 

Auto-suggestions         5,   12,   i6f, 

20,  179,  187,  207,  213*,  217, 

285 


Bacillus  aerogenes  59,  351 

,,         nitrifying .  .          . .      258 

,,         perfringens  59,  351 

,,         pestis        . .          .  .      246 

Back-ache  . .          . .      167 

Bacteria,  disorders  due  to        59, 

226,  228,  242,  246,  259,  262, 

263,  264,  296,  350 

Bacterium  Hyacinthi    257*,  263 

,,  maculicolum  .  .      259 

,,  phaseoli  . .     259 

Balano-posthitis    . .          .  .    139* 

Baldness     . .          . .          . .      229 

Baldwin,  J.  M xvii. 

Ball,  C 115 

Ballenger,  W.  L.  ..  ..  197 
Ball-valve  action  .  .  103,  132 
Balneotherapy  ..  311,  352 
Bandages,  elastic  .  .  334 

Barbier  on  dyspepsia        . .       77 

Barie,  E 36,  41 

Barnard,  H.  L.  . .  . .  95 
Basal  leaf  zone,  turgor  of  260 
Basedow's  disease  . .  67 

Baths,  value  of  cold  311,  352 
Battle  and  Corner  ..  no 

Beans,  disease  of  . .     259 

Beard,  G.  M 140 

Bed-wetting  . .         129,   135 

Belching 98f 

Belt,  value  of  . .  . .  334 
Benzoin  inhalations  .  .  324 


357 


Page 
Beriberi      ..          ...          ..     270 

Berkeley  and  Bonney       . .      148 
Bicarbonate  of  soda          . .     326 
Bichat  on  death     . .          . .      266 

Biliary  calculus  102,  in,  293*, 

298 

„        disorders   100,  103,   118, 
297 

Bing,  A 218 

Binocular  vision,  loss  of          294 

Birds,  disease  in    237,  244,  246, 

252,  254 

Bladder,  atony  of  . .      133 

„     catherisation  of     131,   133 

,,     disorders  of        123*,  I3of, 

139* 

„     neuroses  of  . .      134 

,,     over-distention  of  139*, 

„     paralysis  of  . .    123* 

,,     stammering  of         . .      135 

Blepharitis  ..          ..      182 

Blepharophimosis . .          ..      183 

Blepharoplasty       ..  -343 

Blepharospasm  i7if,   173*, 

174,   183,  235 

Blindness    ..          ..         178,   188 

Blinking,  excessive        173*,  174 

Bloch  on  enlarged  tonsils        193 

Blood,  disorders  of  37*,  6if,  I04f 

„       pressure,  high       II*,  43, 

47,    57,     73*,     74,     266, 

267*,  269,  271 

,,       pressure,  low  40,  63,  267*, 
279*,  284 

„       vessels,  Circles 

associated  with  37*,  S5f 
Blushing  28,  221*,  235,  236 
Boots,  tight  . .  •  •  61 
Botrytis  Douglasii  257*,  261 
Bouillaud,  J.  ..  45 

Boulimia        . .         94,  l6o>   l61 
Bouveret,  L 232 


Bradycardia  . .          . .       39 

Brain,  destruction  of      240,  265 

„       oedema  of  . .       31 

Breaking  of  Circles  by  art      301, 

307*.  315*.  335*,  341* 

,,         of      Circles     by 

drugs      ..     3131,  315* 
,,        of    Circles     by 
hygienic   measures 

305*,  3<>7* 
„        of  Circles    by 

Nature    . .     29if,  293* 

„        of    Circles     by 

operation      338f,  341* 
„         of     Circles     by 
surgical  appliances 

333*,  335* 

Breathing  exercises  ..     312 

Bright's  disease,  cf.  Nephritis 

Brocq,  L.  147,  229,  231,  235,  285 

Broken  wind          . .          . .     243 

Bromides,  abuse  of  . .    283f 

„         use    of          315*,  316 

Bronchiectasis      *   73*,  84,  244 

Bronchitis  40,  73*,  82f,  121,  159, 

170,  243 

Broncho-pneumonia         . .     276 
Brown,  H.  . .          . .      280 

„        L.  ..          ..     329 

Bruce,  M.  . .   3,  54,  85,  94,   101 
Brunton,  T.  L.        100,  304,  306 

Buchanan,  R.  J 62 

Bulb,  anaemia  of       n*,  27,  30, 

43,  267*,  274,  348 

Bulbs,  disease  in   . .          . .     251 

Bunions 224 

Burnett  on  trachoma       . .     172 


Cabot,  R.  C.          ..         62,  116 

Caecum,  inflammation  of  ..  nof 
Calculus,  appendicular     ..     no 


358 


(Dicioua  Circles  in  Snscaec 


Page 

Calculus,  biliary  102,   in, 

293*,  298 

„  dental     ..  ..        88 

„  nasal     ...  ..     199 

,,  pancreatic  . .      103 

„  renal      . .  . .    i27f 

„  ureteral  . .      128 

„  urethral  136,   239*, 
251 

,,  vesical    ..  in,   123*, 

Callosities  . .          . .         224,  331 

Calories  required  in  obesity     160 

,,         wasted  in  faeces        162 

Campbell,  H 158 

Cancer        94 

Capillary  stasis      . .  58,  60 

Carbolic  acid          . .          . .     328 

Carbonaemia,  excessive     64,   163 

Cardiac  arrhythmia  38,  54 

,,      Circles      35f,  37*,  i53f, 

239*,  24of,  305,  307*,  318 

„       dilatation      35,  39,  42f, 

46,  71,   80,   82,   266,   267* 

,,       disease,  congenital     49f, 

271 

,,       dyspnoea  . .          . .     280 

„       failure    35,  37*,  41,  64, 

83,    121,    153,    155*,    156, 

161,  239*,  240,  266f,  270, 

286,   292,   299,   305,   307*, 

„       hypertrophy        45,   158, 
293*,  295 

,,       neuroses  . .  17,  53 

„      strain        . .          42,  266 

,,       tone,  want  of       . .        48 

Cardio-gastric  Circle         . .        42 

Caries,  dental  88,  89*,  90 

Carlsbad  water       . .  .  .      327 

Cascara  sagrada    . .          . .     327 

Cathartics  . .          . .       277,  279* 

Catheter,  Eustachian        . .     336 

„        vesical  131,   133, 

335*,  336 


Page 

Cattle,  disease  in  237,   242,  244^ 

250 

Cauliflowers,  disease  in    . .      259 

Cauteries 338 

Cavities,  pulmonary          . .     242 

Cellular  pathology  . .          2 

Cerebral  anaemia,  cf.  Anaemia 

,,         haemorrhage     n*,  291, 

121,  237f,  267*,  275,347 

Cerebro-spinal  meningitis       3 if, 

348f 

Cerumen,  accumulation  of     211, 
213*,  312,  337 

Cervix  uteri,  strangulation  of  149 
Chalybeate  waters  . .      323 

Chauffard  and  Laederich  68,  122 
Chemical  Circles  8,  96,  326 

Chemosis    ..          ..          ..      182 

Chermes  laricis      . .          . .      263 

Children,  Circles  in      13,  74,  99, 

129,    135,    I7if,    i83f,    185, 

192,  202,  206,  2i7f,  223,  272, 

289 

Chloral        316 

Chloride  of  sodium          311,  329 
Chlorine  gas  . .          . .        78 

Chloroform  . .          . .     286 

Chlorophyll,  want  of     257*,  258 
Chlorosis     .  .  146,   292,  322 

Cholaemia  . .          . .          . .      104 

Cholangitis  . .          . .      103 

Cholecystectomy    . .          . .     339 

Cholecystitis  .  .         89*,   103 

Cholelithiasis    io2f,    in,    293*, 

298,  339 

Cholera       . .          . .  63,  336 

Cholesteatoma       . .      213*,  214 
Chondroids  ..          ..      241 

Choroiditis . .          ..         179,   184 

Church,  W.  S 29 

Cilia,  destruction  of    191*,   I97f, 
211,  213*,  323 

Ciliary  muscle,  over-taxed     294, 
337 


359 


Page 
Circles  associated  with 

bladder  . .     I2if,  123* 

„     associated   with 

blood  . .          . .         37*,  6if 
,,     associated   with 

blood-vessels  37*,  55! 

„     associated   with 

brain  . .  1 1 *,  2gl ,  237 

,,     associated   with 

bronchi  ..         73*,  82f 

„     associated   with 

constitutional  disease    I53f, 
155* 
,,     associated   with 

death,  cf.  Death 
,,     associated  with 

ear      ..          ..     2iof,  213* 
„     associated  with  eye      1711, 
173* 
„     associated  with  heart, 

cf.  Cardiac  Circles 
„     associated  with 

intestines       ..       89*,  io6f 
„     associated   with 

kidneys  ..     I2if,  123* 

,,     associated  with 

larynx  . .     202f,  203* 

,,     associated  with 

liver    ..          ..       89*,  loof 
„     associated   with 

lungs  . .  7if,  73*.  239*.  241* 
„     associated   with 

lymphatics     . .          . .      5^f 
„    associated  with 

mouth  ..         87f,  89* 

,     associated   with 

nails 229 

,,     associated   with 

nervous  system         9f>  "*» 
237* 
„     associated   with 

nose    ..         ..     i89f,  191* 
,,     associated  with 

cesophagus     . .          . .      92* 
„     associated   with 

pancreas         . .          . .    xoof 
„     associated   with 

pericardium  ..         37*.  5<>f 


Circles  associated  with 

pleura  . .         73*,  8if 

,,     associated   with 

prostate  ..  123*,  i3of 
,,  associated  with 

sebaceous   glands          221*, 

230f 

,,     associated   with 

sexual  system  i37f,  139* 
,,  associated  with 

skin  2i9f,  221*,  253,  33if, 
338 
,,  associated  with 

stomach  89*,  93f,  3251 
,,  associated  with 

throat  . .  20if,  203* 

„  associated  with 

ureter  ..  125*,  I28f 

,,  associated  with 

urethra  . .  125*,  I35f 

,,  associated  with 

veterinary  diseases  . .  237f, 
239* 

„  broken  by  Art  . .  3Oof 
„  broken  by  drugs  . .  3131, 

,,     broken   by   hygienic 

measures  . .  3051,  307* 
„  broken  by  Nature  291  f, 

,,     broken   by   surgical 

appliances  ..  333*.  335* 
,,'  broken  by  surgical 

operations  338f,  34  »* 

„     concurrent  Frontispiece,    8 

,,     physiological  24,  324 

„     virtuous  24,  41,  258, 

280,  324,  325 

Circling,  positive  and 

negative  . .  •  •  200 
Circuits,  long  and  short  36,  41 
Circular  reaction, 

definition  of  . .          •  •    xvii. 

Circuit  faclilii      . .     2771,  279* 

,     virtuosi  24,  41,  258, 

280,  324,  325 


360 


IDicious  Circles  in  SMseaee 


Page 

Circulus  necator    . .          . .     347 
.    „      viliosus,  cf.  Circles 
Cirrhosis,  portal     . .          .  .      296 

„  renal      . .  .  .      124 

Clarke,  E.  ..  177,   182,   188 

Classification  of  Circles    . .          7 

Clavus         224 

Cleanliness,  want  of  . .  312 
Clothing,  disinfection  of  . .  332 
Clouston,  T.  . .  . .  308 

Clubfoot      344 

Cocaine,  abuse  of  . .      281 

Codeine       . .  . .        303,  304 

Cohnheim,  J.  . .  . .  58 
Coitus,  difficult  . .  . .  148 

„       unnatural  . .      138 

Cold  baths  ..          ..      311 

„   exposure  to    . .          . .       29 
Colectomy  . .          . .     340 

Coleman,  F.  . .          . .       90 

Coleophora  laricella  . .  263 
Coleosporium  Senecionis  258 
Colic,  flatulent  . .  249,  250 
Colitis  ..  20,  no,  in 

Collaemia 70 

Collapse 276 

„          pulmonary  . .        78 

Collier,  M.  . .          . .     193 

Colon,  dilatation  of  . .      127 

,,       displacement  of     . .      109 

,,       spasm  of     . .          . .      108 

Colopexy     . .          . .          . .     342 

Coma          ..  29,  287,  347 

Comedos     . .          . .          . .     230 

Compensation,  failure  of    40,  42 

Compression,  cerebral        30,  32, 

238,  341,*  347 

Concurrent  Circles  Frontispiece,  8 
Confidence,  loss  of  12,  142,  163 

Congenital  cardiac  disease    49f, 
271 


Congestion,  pulmonary  37 " 


Page 

,73*, 
83 
138 
I7if 
179 


Congressus  interruptus 
Conjunctivitis 
Conservative  spectacles 
Constipation  20,  67,  89*,  108, 
247,  298,  307*,  337 
Constitutional  diseases  i53f, 

155* 

Convulsions    28,  2O5f,  276,  287, 
314,  315* 

Coombs,  C.  F.        . .  47,  270 

Coprostasis,  cf.  Constipation 
Cork,  formation  of         256,   259, 
265 

Cornea,  inflammation  of       173*, 
174 

„          staphyloma  of  174,   178 

,,         ulcer  of    172*,  174,  175 

Corneo-scleral  trephining        347 

Corner,  E.  M.         . .          . .      143 

Corns  224 

Coronary  circulation, 

impaired  42,   157,  266, 

267*,   268,   270,   275,   293*, 

296 

,,  congestion    36,  82,  268 

„  sclerosis  44,  268 

Corpulence,  cf.  Obesity 

Corset,  use  of         . .        106,  289 

Cough     73*,   74,    82,   202,   235, 

242,  274,  292,  296,  303,  314, 

323 

Cramer,  A. 

Creosote  inhalations 
Crime  and  alcohol 
Croom,  J.  H. 
Crop,  distention  of 
Crusts 

Curvature,  spinal 
Cushny,  A.  R. 
Cut-throat 
Cyanosis     . . 
Cycle,  vicious 


20 
324 
28l 
I46 

246 
225 

334 
..  326 
. .  276 

38,  50,  65,  348 
. .        25 


211, 

1 86. 


3nbejr 


361 


Page 

Page 

Cyclitis 

177 

Death  from  hydrothorax 

82 

Cyriax, 

E.  F. 

333 

,,      from  impaction  of 

Cyst,  adenomatous 

208 

food 

246f 

„    retention       .  .         '.. 

103 

,,      from  influenza 

276 

,,    sebaceous 

230 

,,      from  nervous 
disorders 

275 

Cystitis       123*,  I3bf,  133! 
Cytolysins 

,  288 
296 

from  parasitic 
disease        .  .        255, 

263 

,,      from  pericarditis    52 

271 

,,      from  peritonitis 

252 

,,      from  pleurisy 

82 

,,      from  pulmonary 

haemorrhage      267*, 

274 

Dacryo-cystitis 
Damocles,  sword  of 
Dasyscypha  Willkommii 

1  80 
19 
257*. 

262f 

,,      from  respiratory 
disorders     .  .     267*, 
,,      from  ruptured 
aneurysm  .  . 

272f 
271 

Davis, 

E.  D  

77 

,,      from  ruptured 
bladder 

251 

Deafness     ..        213*,  2i4f,  218 

Death  from  aneurysm      . .     271 

,,      from  angina  pectoris    268 

,,      from  apoplexy  238,  267*, 

275 

,,       from  asphyxia      8of,  202, 

204,    209,    244,   267,    272 

„      from  atelectasis     . .     272 

,,       from  beriberi          . .      270 

from  broncho-pneumonia 

276 

,,       from  cardiac  failure     43?, 
46,  266f,  270,  306 
,,      from  chloroform    . .      286 
,,       from  congenital 

heart  disease          .  .      271 
from  convulsions  .  .      276 
,,      from  embolism       . .     270 
,,      from  excessive  venosity 

28,  64,  272 

,,       from  goitre         267*,  272 
,,      from  haemorrhage       238, 

,,       from  heart  disease        43f, 

46,  266f,  270,  306 

,,       from  hydrocephalus      276 


,,  from  ruptured  heart  267*, 
271 
,,  from  ruptured 

intestine  . .  . .  245f 
,,  from  ruptured  valve  269 
,,  from  sepsis  257,  263 

,,  from  shock  267*,  276 
,,  from  starvation  92,  246 
,,  from  syncope  . .  268 
,,  from  thrombosis  . .  270 
,,  from  vaso-motor 

paralysis  . .  30,  275 
„  from  venesection  . .  287f 
,,  from  Vicious  Circles  5, 

,,      from  violence         . .     276 

,,      from  wind-colic     . .       99 

Debility         226,  233,  249,  279* 

Dechlorinisation    ..          ..    3iof 

Decidua,  haemorrhage  into     151 

Decompression      . .        299,  347 

Defaecation,  neglect  of     ..    H3f 

,,  regulation  of      312 

Definition  of  Vicious  Circle  xvii. 

Dench,  E.  B.         ..        212,  217 


362 


H)iciou0  Circles  tn  Bieeaee 


Page 

Dental  calculus  . .  . .  88 

„  caries  . .  88,  89*,  90 

,,  sepsis  . .  87,  90 

Depilatories  . .  . .     229 

Depression,  mental          13,  236, 
279*,  295 

Dermodectes  communis  . .     253 

Desnos  and  Minet  . .      132 

Destruction  of  brain        30,  240, 

265 

,,    eye  178,  265 

„    kidney    126,  251, 

265 

„  „    leaves    257*,  260 

»  .,    lung          •  •     265 

„  ,,    twigs    257*,  26of 

Determann  on  viscosity   . .       64 

D'Etiolles,  L 130 

Diabetes     . .          . .     155*,  i6jt 
„        insipidus  129,  151 

Diaphoresis  . .          . .    328f 

Diaphragmatic  pump, 

weakness  of  . .          . .     158 

Diarrhoea  ..  21,  276,  285 

Digestive  disorders    20,  87f,  89*, 

100,    102,    295,    297,     308, 

324f,  326 

Digitalis 3*8* 

Dilatation  of  bronchi      84*,  244 
„  „  colon  ..     127 

„  heart,  cf.  Heart 
,,          ,,  nasal  tract         191, 
194* 

,,  ,,  cesophagus          127 

,,          ,,  rectum        . .     114 
,,          ,,  stomach,  cf. 
Gastrectasis 

„          „  trachea        . .     244 

„          „  ureter          . .     129 

,,  ,,  urethra        . .      135 

Diphtheria..  43,  201,  203* 

Dispersal  of  parasites   225,  239*, 

253 


Diseases,  self -limiting      ..      121 
Dixon,  W.  E.         . .  85,  86 

Dogs,  disease  in    . .        237,  248 
Domestic  animals,  disease 

in  ..  ..  237f,  239* 
Donders,  F.  C.  . .  . .  179 
Douching,  danger  of  . .  289 

Doyne,  R.  W 186 

Drainage,  arrest  of  . .     241 

,,  value  of        . .        349f 

Dropsy,  cf.  Ascites 

„         pericardial          37*,  sif 

„         peritoneal  52,  113 

„         pleural         52,  73*,  8if 

Drowning  . .          . .          . .     276 

Drugs,  value  of     . .     313^  315* 

Drum,  stretching  of  the  212,  215 

Dubois,  P.  ..  12,   1 8 

Duckworth,  D.      . .         1 53,   165 

Duncan,  J.  M.        129,  146,  150 

Duodenum,  distention  of  95 

„  kinking  of     89*,  95 

,,  obstruction  of      247 

,,  ulcer  of         . .    io7f 

Dyschezia  ..          ..       89*,   H4f 

Dyshidrosis  . .          . .     233 

Dysmenorrhcea      . .          . .      145 

Dyspareunia  . .         145,   148 

Dyspepsia,  cf.  Digestive 

disorders 
Dysphagia . .          . .  77,  204 

Dyspnoea       78,   170,  203*,  2O7f 


Ear,  disorders  of  the   2iof,  213*, 
228 

Earth  hunger         . .          99,    100 
Eclampsia  ..          68,   105 

Ecthyma    . .          . .          -.     228 


363 


Page 

Ectropion  ..  ..  173*,  i8if 
Eczema  173*,  i8if,  211,  2igi, 

221*,    222,    229,    286 

Edwards,  F.  S 116 

Effusion,  pericardial        37*,  $if 

,,       peritoneal  52,   113 

,,       pleuritic     52,  73*,  8if 

Egg-binding  . .      239*,  252 

Ehrnrooth  on  heart          . .       43 

Eichhorst  on  anaemia       . .        63 

Elastin,  loss  of      . .          . .     222 

Electricity,  value  of          . .     338 

Ellis,  T.  S.  . .          . .      224 

Emesis       297f 

Emphysema  83,  86,  159,  243 
Empyema  ..  ..  81,  274 
Endocarditis  ..  48,  88 

Enemata  of  quassia  . .  328 
Enteric  fever  . .  43,  287 

Enteritis 109 

Enteroplasty  . .  . .  342 
Enteroptosis  105,  109,  342 

Entropion  . .  172,  173*,  183 
Enuresis  . .  ..  129,  135 
Enzymes  60,  69,  88,  105,  256, 
262,  295f,  342 
Epididymitis  . .  . .  288 

Epilation 229 

Epilepsy    ii*,  28,  86,  314,  315* 
Epiphora    . .          . .          . .    i8lf 

Epistaxis    . .  196,  292,  299 

Equanimity  . .          .  •       54 

Equilibration  of  forces, 

disturbed      ' . .          . .     292 

Ereutophobia         . .          . .     236 

Erlanger  on  heart-block  39 

Errors  of  refraction  . .  i84f 
Eruptions,  artificial  . .  284f 

Erythema 223 

Eserine,  value  of  . .  . .  33°* 
Eucles  ..  ..  42,  266 


P««e 

Euphoria    . .          . .          . .   279* 

Eustachian  catheter          . .     336 

„  obstruction  21  if,  336 

Evans,  J.  J.  . .          . .      180 

Ewald,  C.  A.          . .  93,  98 

Exercise,  insufficient      159,   162, 
164,  221*,  233 

,,        physical  . .      308 

Expectorants          . .          . .     323 

Explosions,  injuries  due  to    209, 

217 

"  Explosive  method,"  the       294 

Expulsion  of  calculus       . .   293* 

Extraordinary  mechanisms   297f 

Eye,  disorders  of  the  I7if,   173*, 

265,  347 

,,     strain,  cf.  Asthenopia 


Faecal  concretions  ..     in 

,,      stasis,  cf.  Constipation 
Failure,  cardiac,  cf.  Cardiac 
Fainting     . .          . .          . .       27 

Fallopian  tube,  kinking  of      150 
Falstaff       ....  ..164 

Fat,  excess  of,  cf.  Obesity 
Faure  and  Siredey  . .     144 

Favus         237 

Feet,  tenderness  of  ..      165 

Female,  disorders  in  the          144 
Fermentation  of  food     245,  247, 
293*.  297*.  326 
Fever,  enteric        . .          43,  287 

„       hay 200 

„       milk  ..          ..    25if 

,,      rheumatic  . .       48 

Fibrillation,  auricular        38,  319 

Pick,  A 178 

Fischer,  M.  H 124 

„         on  glaucoma      . .     177 


364 


IDicious  Circles  in  Disease 


Page 

Fissure,  anal          . .          . .  115 

Flat-foot     . .          167,  333f,  346 

Flatulence                41  f,   119,  283 

Fleas,  disease  in    . .          . .  246 

Fleming,  A.            . .          . .  351 

Floating  kidney     . .         126,  342 

„          liver         ..         1 06,  342 

Foetus,  giant          ..          . .  151 

Foie  cardiaque       . .          . .  41 

Folie  circulaire      . .           28,  306 

Food,    impaction  of        237,  245 

,,       regulation  of          .  .  309 

,,       restriction  of          . .  309 
Foramen  magnum, 

plugging  of     . .          . .  276 

„            ovale,  patent     . .  49f 

Forsyth,  D.             . .          . .  51 

Fowls,  disease  in             244,  254 

Fox,  W 232 

Frankel,  A.             . .         71,  2o8f 

Frantzel,  0.            . .          . .  54 

Fraser,  J.  S.           . .          . .  192 

Frostbite 60 

Fuchs  on  deferred  delivery  151 

,,        ,,  epiphora            .  .  181 

Fungi,  disorders  due  to    . .  226 

Fiirbringer,  P 138 

Furunculosis                         .  228 


Galen          . .          . .          . .     xix. 

,,      veins  of        . .  .  .        32 

Gall-stones   iO2f,  m,  293*,  298, 

339 

Gangrene    .  .          .  .         59f,  342 

Gant,  S.  G.  . .          . .        21 

Gapes,  the  . .  . .      244 

Gas  gangrene         . .          . .        59 


Page 

Gassing  by  chlorine  . .        78 

Gastrectasis          3,   94,   99,   119, 

127,    160,   283,   293*,   298f, 

327,  34° 

Gastric  Circles  89*,  93f,  245,  340 

,,        neuroses    . .          . .        19 

,,        tympany    . .          . .      249 

,,        ulcer  97f,  342 

Gastritis        93f,    119,    248,    325 

Gastro-enterostomy  . .        93 

Gastro-jejunostomy          . .     343 

Gastropexy  . .  . .      340 

Gastroplasty  . .          . .     342 

Gastroptosis  89*,  95,  340 

Gaucher,  E.  . .          . .      224 

Gentian 325 

Genu  valgum         . .  . .     345 

Geophagy 99f 

Giant  foetus  ..          ..      151 

Gibbons,  R.  A 147 

Gibson,  G.  A.         . .  45,  52 

Gilbert,  A.  . .          . .       69 

Gilford,  H.  ..  27,   166 

Giddiness  . .  .  .  158,  163 
Glans,  strangulation  of  142,  344 
Glaucoma  173*,  I75f,  330,  347 
Globus,  hystericus  .  .  207 

Glottis,  narrowing  of  . .  207 
Glycaemia  . .  155*,  i67f 

Glycosuria  ..          ..    i67f 

Goadby,  K.  . .          . .        90 

Goats,  disease  in  . .  . .  244 
Goitre  203*,  208,  267*,  272 

Gonorrhoea  135,   171,   288 

Goodell,  W 149 

Goodhart,  G.  F 187 

Cradle,  H.  . .        194,  214 

Green,  E 185 

Griinwald,  L.          ..          ..      197 

Guisez,  J 211 

Gull,  W.  W 24 


365 


Gums,  recession  of 
Guttural  pouches 
Guyon,  F.  . . 


Page 

88 

241 

134 


Habit  Circles         ..        235,  250 

„      spasms         . .  28,  86 

Haematemesis        ..        274,314 

Haematuria  . .          . .     299 

Haemopoiesis,  defective  62,  155*, 

315*,  322 

Haemoptysis   57,  73*,  267*,  274, 
292,  299,  314 

Haemorrhage  ..         57,  62 

cerebral    n*,  29f, 
237,  267* 
gastric    293*,  299 
,,  intestinal    . .      299 

„  pulmonary,  cf. 

Haemoptysis 

Haemorrhoids        ..       115*.  349 
Haemostasis,  natural        . .        75 

Haig,  A 7<>,  3io 

Hair,  disorders  of  . .     228 

Halls  Dally,  J.  F.  8,  41 

Halluxvalgus        ..          .-346 

Hanging 276 

Hare,  F 74,  "4 

Harman,  B 182 

Hats,  hard-brimmed         . .     229 

Hay  fever 200 

Headache  23,  187,  287,  295,  337 

Heart,  arrhythmia  of          38,  54 

„       block          ....       39 

„       dilatation  of    35,  39,  42*. 

46,  71,  80,  82,  158,  266,, 

disease,  congenital       49f, 
271 


Page 
Heart  failure,  cf .  Cardiac 

,,       hypertrophy  of     45,   158, 
293*,  295 

„       neuroses  of     17,  53,  321 

,,       rupture  of  39,  271 

,,       strain  of     . .  42,  48 

,,       tilting  of     . .          . .       42 

„       valvular  disease  of      37*, 

45' 

Heat-regulating  mechanism  164 

Heath,  C.  J 215 

Hemicrania  . .          . .       25 

Hepatic  disorders  41,  iO4f,  296 
Hepatopexy  . .  . .  342 

Hepatoptosis          . .          . .    tosf 

Herman,  G.  E 23 

Herman  and  Maxwell  22,  146 
Hernia  89*,  109,  341*,  344 
Hetero-suggestion  . .  14 

Hewlett,  A.  W 164 

Heymann,  P 198 

Hill,  L 31 

Hippocrates   ax.,  118,  299,  351 

Hirschfelder,  A.  D.    38,  47f,  50, 

67,  269,  281 

Hirsuties 229 

Hoare,  E.  W 249 

Holland,  H 278 

Holmes,  G 140 

Homer        332 

Hook  and  Kanaval  . .     34» 

Horace       «5 

Hormone,  production  of          116 

Horses,  disease  in       237f,  240f, 

247* 

Horsley  and  Sturge  . .     283 

Huchard,  H 4<> 

Hiihner,  M I5<> 

Hunger-pain         ..         ••     160 

„       psychical  ..     325 

Hunter,  J.  . .          . .       28 


366 


IDidous  Circles  in  Disease 


Page 

Page 

Hunyadi  Janos  water       .  .     327 

3 

Hurst,  A.  F.           ..          ..217 

Ideation,  perverted           n*,   i5f 

Hutchinson,  J.       .  .        230,  235 

Immunization        .  .          .  .        72 

Hyacinth  bulbs      .  .          .  .    263f 

Impetigo     ..         221*,  228,  253 

Hyde,  J.  N  223 

Impotence              .  .          .  .    141  f 

Hydrocephalus    n*,  30,  32,  179, 
238,  276,  348 

Inanition    .  .          .  .       155*,  168 
Inattention  and  deafness  .  .      215 
218 

Hydrochloric  acid              .  .     326 

Indolence   .  .        155*,   158,   i6if 

Hydronephrosis   123*,  I26f,  25of 

Inflammation         .  .           .  .      58f 

Hydropericardium             .  .        52 

Influenza    .  .          .  .          43,  276 

Hydrotherapy        .  .          .  .      311 

Injudicious  treatment       .  .    277f 

Hydrothorax          .  .          .  .        82 

Insanity      .  .           28,  289f,  3o6f 

Hygienic  measures  break 

Insomnia  5,  isf,  23,  41,  76,  140, 

Circles             ..     3o5f,  307* 

187,     213*,     2l6,     222,     236, 

Hymenolepis  nana            .  .      100 

295,  313 

Hyper  aesthesia       .  .             23,  90 

Insufficiency,  hepatic        .  .    iO4f 

,,              of  nose     .  .     200 

Inter-dependence  of  organs      if, 

7,  291,  354 

,,              ,,    ovaries        145 

Intertrigo             .  .          223,  312 

,,             „  retina  .  .    i78f 

Intestinal  disorders        89*,   io6f 

»              ..   vulva   .  .  139*, 

245f 

Hyperchlorhydria    g6i,  326,  342 

Hyperhidrosis    164,    221*,    223, 

232 

Hyperkeratosis  224,  230,  235 
Hypermetropia  ..  186,  337 
Hyperthyroidism  . .  . .  66f 
Hypertrichosis  . .  . .  229 

Hypertrophy,  cardiac      45,    56!, 
158,  293*,  295 
„  prostatic    132,  340 

Hypochondriasis  20,  140,  217 
Hypodermoclysis  . .  . .  336 

Hypoendocrinism .  .  . .  320 
Hypopituitarism  . .  . .  163 
Hyposphyxia  . .  . .  320 
Hypothyroidism  ..  112,  163 
Hysterectomy  . .  . .  339 

Hysteria  ..  . .  n*,  23f 
Hysteropexy  ..  , .  340 


„       stasis,  cf.  Constipation 
,,       tympany  . .    249f 

Intra- venous  injections    . .     336 
Intussusception     ..         113,  342 
Invalidism,  chronic  . .      259 

Iodides,  use  of       . .          . .    284* 

lododerma..          ..          ..     284 

Ipecacuanha          . .          . .     323 

Iridectomy  . .          . .     327 

Iritis  ..          ..          88,   175 

Iron  322f 

Irons,  use  of          . .          . .     289 

Irrigations,  injurious        . .      288 

„  value  of         . .     337 

Isodynamic  factors  . .     292 


Jackets,  spinal 
Jackson,  H. 


289 
206 


367 


Jacquet,  L. 
Jaundice 
Jeliffe,  S.  E. 
Job 

Jones,  M 

R 

Joyce,  J.  L. 
Judson  on  coughing 


Page 

••  235 
104,  337 
••  25 
••  15 
..  MS 
••  34 
..  131 
..  76 


Kaposi,  M. 
Keratitis     . . 
Keratoconus 
Keratoma  . . 
Kerion 


2i9f,  292 

173*.   174 

••      175 

..     230 

••     330 


Kidney,  calculus  of          . .    I2yf 

,,          cirrhosis  of          . .      124 

destruction  of    126,  251, 

265 

„          disorders  of  the  69,   121 

„         movable  . .        125,  342 

,,          tuberculosis  of    . .      126 

King  William  Rufus         . .     271 

Kinking  of  duodenum    337,  340 

,,         ,,  Fallopian  tube       150 

„  pylorus         337,  34° 

,,         „  ureter        123*,  126, 

250 

Klebs-Loffler  bacillus  201,  203* 

Knee  joints,  painful  . .      167 

Knock-knee           ..  . .     345 

Koranyi  on  obesity  167 

Krafft-Ebing,  R.  . .  16,  141 

Krehl,  L.    .  ..162 

Kuhnt  on  sinusitis  . .      198 

Kuschel  on  glaucoma  . .      17° 

Kiistner  on  abortion  . .      IS1 


* 

Lachrymal  sac,  excision  of     340 

„         stenosis  180,  336 

Landolt,  E.  ..         1 79,   184 

Lane,  A 120 

Larch,  disease  in  . .  . .  262f 
Laryngismus  . .  . .  205 

Larynx,  disorders  of       77,  2O2f, 
203*,  286 

„         polypus  of       203*,  204 

,,         spasm  of  205,  286 

,,         tuberculosis  of    . .     204 

Lassitude    ..          ..        233,  325 

Latham,  A.  86 

Lawson,  A.  174,   176,   185 

Lea,  E 38 

Leaf-shedding  disease       . .     260 
,,  -spot  disease  . .          . .     259 
,,  zone,  basal     . .          . .     278 
Leaves,  destruction  of   257*,  260 
Leguminous  plants  . .     258 

Lens,  value  of  artificial  . .  337 
Lenzmann,  R.  ..  IS2,  273 
Leubuscher  on  obesity  . .  165 
Leucorrhcea  ..  MS.  289 

Lewandowsky,  M.  5»  39 

Lewis,  B 133 

Lice  ..          2251,  263,  332 

Lichenification  . .  220,  234 
Liebreich  on  myopia  186 

Ligaments,  stretching  of        333, 
345 

Ligation  of  vessels  . .     349 

Liquids,  restriction  of  . .  309 
Litholapaxy  •  •  343 

Lithotomy  •     343 

Lithotrity «33* 

Liver,  disorders  of    41,  69,  ioof, 
161,    169 

„      floating       ..       105*.  342 
Llewellyn  and  Jones         . .     233 


368 


IDicious  Circles  in  Disease 


Page 

Page 

Lobisch  on  obesity            ..      163 

Massage                   334,  346,  352 

Longmore,  T.        .  .          .  .     226 

Mastication,  defective       .  .        91 

Lophodermium  pinastri        257*, 

Masturbation            22,   137,   141 

260 

Mathieu,  A.               20,  309,  326 

Lorisch,  H.            ..          ..162 

,,      and  Roux      19,   97,   99, 

Loughnane,  F.  M.             .  .       61 

108,  324 

Lousiness  .  .          225f,  263,  332 

Maxillae,  malformation  of        90, 

Lunacy       .  .         138,  279*,  308 

194 

Lungs,  disorders  of  the           xx., 

Mechanical  Circles            .  .          8 

7i*.  73*,  239*,  241,  244 

„     supports,  abuse  of  .  .      289 

Lymphatic  pump  .  .             51,  81 

,,             ,,        use  of       .  .    333f 

Lymphatics,  pressure  on        37*, 

Mechanisms,  extra-ordinary  297f 

Si,  73*.  81 

Melaena      .  .      13,  15,  217,  299 

,,             varicose        .  .       58 

Melancholia           .  .             13,   17 

Lymphatism           .  .          .  .     209 

"  Memory  of  the  body  "            28 

Meningitis              ..        3if,  348f 

Menorrhagia          M5f,  292,  322 

Mercury,  ointment  of       .  .     328 

# 

„         perchloride  of   .  .     322 

Meteorism              ..        112,  342 

Macleod,  J.  M.  H.             .  .     235 

Metritis       .  .          .  .          .  .      145 

McBride,  C.  A  282 
McCallum,  W.  G.              .  .     102 

Metrorrhagia         .  .          .  .     146 
Meyer  and  Gottlieb           .  .      286 

McCarrison,  R  112 

McDonald,  G  196 

Migraine     .  .          .  .          .  .      25f 
Milk  fever              .  .          .  .    25  if 

McKenzie  on  polypi          .  .      199 
„             on  rickets         .  .      170 

,,     stagnation  of          .  .     252 
„    value  of         .  .          .  .     311 

McKisack,  H.  L  46 
Magnesium  sulphate         .  .     329 
Majendie,  foramen  of       .  .       31 
Male,  sexual  disorders  in  the 
137* 

Mineral  waters      .  .        323,  327 
Mining  moth          .  .           .  .      263 
Mitchell,  W  24 
Mitral  regurgitation          .  .      47f 

Mallophagia           ..          ..250                .,       stenosis       ..          ..        47 

Malnutrition     24,  90,  i68f,  204            Monod,  G.              .  .          .  .      104 

Mandible,  contraction  of  90,  194            Monro,  foramen  of                     25 

Mange         253 

Morison,  A             .  .          •  •        55 

Mania             28,  270,  290,  3o6f 

Morphia    278,  279*,  28of,  3131, 

Manson,  P.             ..         I",  270 

315*,  321 

Marasmus               .  .          •  •      285 

Morris,  H.              .  .         128,   142 

M.    .                              220,    222 

Marathon  race       ..          42,  z66 
Martinet  on  "  hyposphyxia  " 
161,  320 

Mors  ex  circulo  vitioso   .  .     265 
Mortimer,  J.  D.  E.            .  .     206 

369 


P«ge 

M-shaped  colon  . .  . .  109 
Mott,  F.  W.  19,  28,  33,  316 
Moullin,  M  ..  107,  130 

Mouth-breathing        191*,    I92f, 

312,  348 

„  disorders  of  the  87,  90 
Miiller,  F.  C.  . .  22,  137 
Mummery,  J.  P.  ..  ..  in 
Muscae  volitantes  163,  178,  187 
Muscles,  disorders  of  34,  i65f, 

333,  346 
Musser  and  Kelly  . .  103 

Muthu,  D.  J 74 

Mutism 209 

Myocardium,  disorders  of 

the    351,  37*,  157,  240,  296, 

305,  3i8 
Myopia  173*,  179,  1841,  293*, 

294,  337 

Myotics,  value  of  . .  330 

Myxomycetes  258,  261 


Nails,  the    .  . 

22<)l 

Narcosis 

8of 

Narcotics,  use  of   .  . 

278, 

313* 

Nasal  calculus 

199 

,,     catarrh 

189, 

199 

,,     dilatation     .  . 

191*. 

I94f 

,,     disorders 

1891, 

191* 

,,      neuroses 

200 

„     polypus     191*, 

196, 

I98f, 

349 

,,      stenosis      i89f, 

191*1 

194 

,,      ulceration    .  . 

195* 

Nascher,  I.  L. 

114 

Nasi,  collapse  of  alae 

194 

Naso-pharynx,  catarrh  of 

192 

Nature,  breaking  of  Circles 

by       ..          ..      29if,  293* 

Nausea,  value  of   . .          . .     295 

Necrosis      . .          . .          . .        59 

Neoplasms  ..        204,  348 

Nephritis     68f,  105,   I2if,  123*, 

I24f,  156,  276,  310,  328 

Nephrolithiasis       . .          . .      127 

Nephrolysins          . .          . .       68 

Nephropexy  . .          . .     342 

Nephroptosis          ..       123*,  125 
Nervous  system,  disorders  of 

91,    ii*,    1621,   237f 
Neuralgia   . .          . .          . .       23 

Neurasthenia   5,  9,  n*,  98,  106, 
115,  138,  i44f,  173*,  i87f, 

213*,     2l6,     232,     282f,     306, 

3131,  337 

,,  traumatic  . .       14 

Neuron  threshold,  lowered       10, 

MS,  3*3 

Neuroses,  aural      . .          . .     216 
„  cardiac  I7f,  53f 

,,  cutaneous         . .     234 

,,  gastric  . .          . .        19 

„  nasal    . .         . .     200 

„  ocular   ..          ..    i87f 

,,  paroxysmal       27,  200 

„  sexual    22,  137,  139*, 

1 44 

,,  traumatic         . .       14 

Night  sweats          ..          -.233 

,,     terrors         . .          . .       13 

\imia  diligentia  ..          . .     290 

Nitrites,  value  of  . .          . .     321 

Noorden,  C.    154,  156,  160,  162, 

1 66 

Nose,  disorders  of  the  i89f,  191*, 
200 

Nothnagel,  H.       ..  .112 

Nutrition,  disorders  of     24,  iS3f 

,,  regulation  of   . .     309 


370 


IDicious  Circles  in  Disease 


. 

Oak  twigs,  death  of  . .      260 

Obesity  53,  78,  153!,  155*,  221*, 

232f,  306,  309 

Obsessions  ..   19,  21,  236 

Obstruction,  biliary          104,  no 

Eustachian        21  if, 

336 

,,  intestinal  in,  249, 

342 

„  lachrymal  180,  336 

„  nasal       i8gi,  191*, 

312,  331 

,,  pancreatic    ..      no 

„  salivary        ..     no 

CEdema       ..  201,  318,  329 

„         cerebral    ..          ..       31 

,,         pulmonary  40,  y8f 

CEsophageal  disorders    92,     127, 

336 

Ofenheim,  E.          . .  67,  109 

Ogston's  osteotomy  .  .     346 

Onychia  maligna  . .          . .      230 

Onychogryphosis  . .          . .      230 

Onychomycosis      . .          . .      227 

Ophthalmia  ..       171,   173* 

,,     neonatorum  171,  183 

„     tarsi  ..          ..      181 

Opotherapy  . .        320,  330 

Oppenheim,  H.      ..  ..      137 

Oral  disorders        . .  87,  goi 

Organectomy         ..      339,  341* 

Organic  Circles      . .  8,  72 

Organopexy     ..   340,  341* 

Organoplasty          ..      341*,  342 

Organs,  destruction  of    126,  240, 

251,  256,  257*,  259,  265 

„         inter-dependence  of 

if,  7,  291,  354 

Orgasm,  cutaneous  . .     234 

Orthopaedic  disorders   167,  333f, 

344* 


Page 

Osteo-myelitis        . .          . .        88 

Osteotomy  . .          . .    23$f 

Oswald  on  thyroidism      . .        67 

Otalgia        ..          . .      213*,  218 

Otitis  . .          2oif,  212,  348 

Otomycosis  . .          . .      227 

Ova,  dispersal  of    225,  239*,  332 

Ovary,  congestion  of         . .        22 

,,        extracts  from  the  . .      320 

„        hyperaesthesia  of        115, 

MS 

Oviduct,  distension  of    239*,  252 
Oxyurides       116,  225,  229,  328 


Paget,  J 135,   140 

Pain    22,  173*,  213*,  218,  313, 

315*.  326,  343 

Palpitation     17,  41,  54,  158,  287 

Panas,  F 181 

Pancreas,  disorders  of    100,  103, 
297 

Papillcedema          ..          ..    i79f 

Paracentesis  . .  81,  350 

Paralysis,  abductor  . .      206 

,,        general..          ..       28 

„         intestinal      112,  341*, 

342 

,,         muscular  33,  317 

„         respiratory      238,  273 

,,         spastic  . .          . .       34 

,,         thermotaxic      . .        29 

,,         vaso-motor      26f,  275 

,,         vesical  . .       123*,   133 

Paraphimosis        139*,   142,  344 

Parasitic  disorders         99f,     116, 

210,   225f,   237,   239*,   244, 

254,  256,  257*,  299,  328,  331 

Paroxysmal  neuroses        . .        27 


371 


Page 

Page 

Parturition,  disorders  of  .  .    isof            Pine  Needle-cast   .  .          .  .      261 

Pathology,  cellular            ..         2            Pinto,  G.     ..          ..          ..      175 

Paunch,  impaction  of       .  .     245            Plant  lice    .  .          .  .          .  .      263 

Pavlov,  J.  P.          ..          ..     319            Plants,  disease  in      5,    14,   255f, 

Payne,  J.  L.           ..          ..       91                                                  257*,  354 

Pectoris,  angina      45,    53f,   268,                  »       leguminous             .     258 

321 

Plethora     161 

Pediculosis             ..        225,  332            Pleurisy         73*,    8if,    121,    349 

Penis  captivus        .  .          .  .      150            Pneumonia   40,  43,  7if,  88,  287, 

Pericarditis     37*,  5if,  271,  349 

Peridermium  pini              .  .     258            Poliomyelitis                      33,  345 

Perinseum,  ruptured         .  .      340            Polycythaemia                  6sf,   105 

Peristalsis,  impaired  93,  98,  109, 

Polypus,  aural       .  .         214,  349 

114,    116,    161,    239,*    245, 

laryngeal             .  .   203* 

247,  283,  298,  327                M           nasal     I9I*f   I96(   198f 

„          increased        .  .     298 

,,          removal  of         .  .     349 

Peritoneal  effusion            ..      113 

Pompholyx             .  .           .  .      233 

Peritonitis                        252,  287           Poplar  ^.^  death  of             26o 

Pernet,  G.                                                    Portal  cirrhosis      ..          ..296 

Pernicious  anaemia           .  .        63            Potassium,  iodide  of         .  .    284f 

Perspiration,  excessive      .  .    232f 

nitrate  of        .  .     324 

Pessary,  use  of      .  .        334,  342 

Pottenger,  F  76 

Pessimism,  evils  of            ..        13 

Pouch,  cesophageal           .  .       92 

Pharyngeal  spasm             .  .      207 

,,        prostatic    .  .          .  .      132 

Phimosis     142 

,,        vesical       .  .          .  .      132 

Phlebotomy            ..          ..     347 

Pouches,  guttural  .  .          .  .      241 

Phlyctenular  ophthalmia         171            Poverty  and  alcoholism   ..    28  if 

Phobias    n*,  I2f,  18,  218,  234,            Poweii   D                                     S3 

236,  313 

Photophobia           ..       I73M74            Pregnancy,  disorders  of    . 

Physiological  Circles         24,324            PreSby°Pia 
Pressure,  increased  mtra- 
Phyto-pathology  xix.,     *    2S5f,                   cfania,                 f    ^  ^ 

257   >   354 

Pritchard,  E  109 

Pica             .  .          •  •          •  •       99 

Pick  and  Hecht     .  .        168,  274 

Procidentia  of  uterus    148,    340, 

Pickerill,  H.  P.             8,  91,   194 
Picking  of  nose      .            .  .    I96f 

Prolapse  of  rectum           ..      115 
,,  uterus                 139*. 

Pigs,  disease  in      .  .            .      244      |                                      I48,  294,  340 

Piles           ..  '      ..       "5*.  349 

Prostate,  disorders  of            123*, 

Pilocarpine                           •     329 

130,  132,  340 

Pine  Blister                        •     258 

Proverbs,  book  of  .  .          .  .     282 

„     Leaf-scurf     ..          ..261 

Prurigo       ..         *.         ..     235 

372 


IDictoue  Circles  in  ^Disease 


Page 

Pruritus,    116,    146,    211,    221*, 

234,  332 

Psilosis        . .          . .          . .      in 

Psychical  disorders  lof,  n* 

Psychotherapy       . .          . .     352 

Pulmonary  cavities,  formation  of 
76,  242 

,,  congestion    37*,  7if, 

73*,  83 

,,  emphysema     83,  86, 

159,  243 

,,  haemorrhage        73*, 

74,  267*,  292 

,,  oedema  40,  78f 

„  stenosis  . .       49 

Pump,  diaphragmatic       . .      158 

„       lymphatic  . .       51 

Punctum,  eversion  of  173*,    181 

Purgation,  excessive          . .    278f 

Pus,  injury  due  to  60,    350 

Pylorus,  kink  of  337,  340 

„          spasm  of  96f,  326 

,,        stenosis  of  . .        94 

Pyonephrosis         ..          ..      128 

Pyorrhoea  90,  119,  312 


Quack  remedies 

Quassia 

Quinine 


..     277 

325,  328 

••     325 


Rams,  disease  in  . .  . .  251 
Rational  therapeutics  333,  354 
Rats,  disease  in  . .  . .  246 
Rayner,  H.  . .  . .  25 

Rays,  value  of  Rontgen   . .    337f 


Page 

Rectum,  dilatation  of       . .      114 

,,         stenosis  of          . .     336 

Recumbency         293*,  294,  305 

Refraction,  errors  of       184,  337 

Regurgitation,  aortic     37*,   461", 

293*,  296 

,,  mitral        . .      47f 

,,  tricuspid   . .        48 

Reichmann,  syndrome  of         97, 

326 

Renal  disorders     ..      I2if,  123* 
Renin          ..  ..  ..      122 

Resin,  exudation  of       256,    258 

Resistance,    lowered   4,    72,    82, 

84,     90,     124,     159,      175, 

184,     200f,     216,     255,     257*, 
263,    311 

Respiratory   disorders     71,    73*, 

78,    120,    155*,    is8f,    170, 

241*.  323 

Rest,  excess  of  ..  i66f,  308 
,,  value  of  294f,  305f,  314, 

334 

Restraint  in  insanity    279*,   289 

Retention  cysts      103,    230,   234 

,,          of  urine     123*,     I3if, 

135,  335*,  336,  340 

Retinitis i78f 

Retroversion  of  uterus  139*,  150 
Rheumatism  48,  175,  232f 

Rhinitis  i89f,  I94f,  198,  200, 

331 

Rhinolith  ..  ..  191*,  199 
Rhinophyma  . .  . .  232 
Rhythm  in  pathology  . .  27f 
Ribary,  U.  ..  . .  196 
Ribs,  deformity  of  . .  170 
Rickets  155*,  i68f,  272,  345f 
Rigidity,  muscular  206,  286 
Ringworm . .  226,  253f,  338 
Riseley,  S.  D.  . .  . .  192 
Ritchie,  J.  . .  . .  64 
Robin,  A 119 


373 


Robin  and  Dalche"  115,    147 

Romberg,  E.          . .  58,   125 

Rontgen  ra7s,  use  of  . .     337 

Roose,  R ..       62 

Root  starvation     . .  3,  257* 

Roussy  and  Lhermitte  . .     236 

Routh,  A.  . .          . .  22,     144 

Roux  on  gastic  ulcer  . .        97 

Rufus,  King  William  . .     271 

Rumen,  impaction  of  . .    24$f 

Rupture  of   aneurysm  57,    271 

„          ,,    aortic  valve  46,  269 

„         „    heart  39,  267*,  271 


Sabouraud,  R.  . .  . .  227 
Sajoux,  L.T.M.  . .  303,  350 
Salicylic  acid  . .  . .  331 

Saline  injections  . .  . .  336 
Salivary  duct,  obstruction  of  no 
Salpingitis  . .  . .  150 

Salt,  restriction  of  124,  31  of 
Sap,  arrest  of  . .  . .  258f 
Sarcoptes  scabiei  . .  . .  253 
Scabies  225,  239*,  253,  285,  331 
Scabs  ..  191*,  197,  253 

Schafer,  E.  A 78f 

Schizomycetes       . .       258,    261 

Schofield,  A.  T 24 

Schrotter,  L 204 

Sclerectomy  . .          . .     347 

Sclerosis,  coronary  44,  268 

Sclerostomum  vulgure  ..  241 
Scott  on  bronchitis  . .  85 

Scybala,  formation  of  ii4f,  312 
Seborrhcea  23of,  236,  312 

Sebum,  retention  of     221*,  23if 
Secretin,  production  of     ..      118 
value  of  .  •     320 


Self-abuse  . .          . .    i37f 

,,  -consciousness  . .     236 

,,  -control,  want  of         . .     282 

,,  -dependence  of  heart  42 

„  -garotting        . .          . .     207 

,,  -limiting    diseases      ..     121 

Sepsis,  dental  87,  89*,  90 

,,       intestinal    109,  112,  118, 

342 

Septum,  deflection  of        . .      190 

„       ulcer  of     . .        191,   196 

Sequeira,  J.  . .          . .     228 

Serum,  anti-diphtheritic  . .     329 

Sexual  disorders    22,  I37f,  139*, 

164 

Shattock,  S.  G 127 

Shaw,  C.     . .          . .          . .     295 

Sheep,  disease  in  . .       244,    253 

Shock  ii*,  26,   1 88,  209*,  284, 

317.  336 

Sinusitis      ..          191*,  195,  197 

Sippy,  B.  W 96 

Skin,  disorders  of  164,  2igi,  221* 

Sleep,  disorders  of,  cf.  Insomnia 

„      value  of       . .       295,  3i3f 

Slime  fungi  . .          . .     258 

Smegma,  accumulation  of  139*, 

i6sf,  312 

Smith,  E.  F.  . .        259,  262 

..     P 175,  330 

Smuts,  cereal         . .          . .     261 

Sodium  bicarbonate          . .     326 

„         chloride    ..        311,  329 

„         nitrite        . .          . .     321 

„        sulphate   . .          . .     327 

Sophocles 338 

Sorauer,  P.  . .          . .      260 

Spasm,  habit          . .          . .       86 

,,        of  intestine  97,  lO7f,  326 

„         „  larynx  . .        205,  286 

,,         ,,  oesophagus       . .       92 


374 


UMcfous  Circles  In  Disease 


Page 

Spasm  of  pharynx  . .      207 

„         ,,  pylorus  96f,  326 

,,         „  sphincter  ani    ..    iisf 

Spasmophilia         . .          . .        92 

Spear,  I.  J.  . .          . .        12 

Specific  Vicious  Circles  4,  8,  255, 

264 

Speech,  loss  of  . .  . .  209 
Spermatorrhoea  . .  138,  140 
Spermocystitis  . .  . .  138 

Spicer,  S 189 

Spinal  curvature  . .  186,  334 
„  jackets  . .  . .  289 
Spiral,  vicious  . .  . .  18 
Splanchnoptosis  106,  109,  334 
Splenectomy  . .  . .  339 

Sprains        ..          ..          ..      167 

Spriggs,  E.  1 116 

Sprue  in 

Stammering  . .      203*,  207 

„  of  bladder     . .      135 

Staphyloma  of  choroid  174,  178, 

293*,  294 

Starck,  H.  . .          . .       92 

Starvation,  death  from     . .      246 

Stasis,  capillary     . .  58,  60 

„       intestinal  iO9f,  247, 

251,  342 

,,       venous        . .          . .      154 

Status  epilepticus     28,   276,  313 

Stenosis,  aortic      . .          . .      269 

,,         lachrymal         180,  340 

„         mitral     . .          47,  269 

„         nasal  1891,  191*, 

192,   194 

„         oesophageal        . .      336 

„         pulmonary          . .        49 

„         tracheal       203*,    2o7f, 

208,  267*,  272 

Still,  G.  F.  ..          ..      170 

Stocker  on  alcoholism      . .     282 


Page 

Stomach,  disorders  of      41,   89*, 

93f,  239*,  2451,  249f,  337, 

340 

,,       tube,  use  of        . .      337 

Stomatitis,  aphthous         . .        91 

Strain,  cardiac       . .          42,  266 

Strait  waistcoat,  abuse  of        289 

Stramonium  ..          ..     324 

Strangulation  of  cervix  149,  344 

„  ,,   glans      . .      142 

,,  ,,    hernia  n6,  344 

„  ,,   papilla   ..      1 80 

„  „   piles       ..      116 

Stricture,  intestinal  . .     344 

,,          lachrymal        180,  336 

,,          urethral         123*,  135 

Strongylus  infection     239*,  241, 

244 

Strumpell,  A 21 

Strychnine     279*,  284,  317,  325 

Sturgis  on  coitus  . .          . .      138 

Stuttering  . .  . .  28,  207 

Subthyroidism        . .          . .        67 

Suffocation,   cf.   Asphyxia 

Suggestibility,  increased  . .        23 

Sulphate  of  magnesium    . .     329 

,,         ,,   soda    . .          . .      327 

,,         ,,   zinc    . .          . .      327 

Sulphur       . .          . .         285,  332 

Supports,  abuse  of  . .      289 

,,          value  of  . .    333f 

Surgical  appliances  break 

Circles  ..     333f,  335* 

,,         operations  break 

Circles  . .     338f,  341* 

Sweating,  excessive      164,  221*, 

223,  232 

Sycosis        228 

Sylvian  aqueduct,  blocking 

of         . .          . .          32,  238 
Symptomatic  treatment    . .    3O2f 


375 


Page 
Symptoms  cause  Vicious 

Circles             ..           15,  303 

Syncope 268 

Syngamosis             . .      -     . .  244 

Syngamus  trachealis         . .  244 

Syphilis       . .          . .         175,  208 

Syringing,  dangers  of        . .  288 


Tachycardia  17,  40,  319 

Tanzi  on  morphia  . .      280 

Tape- worm  . .          . .      100 

Tarsectomy  . .          . .     346 

Tartar,  deposition  of  . .  88 
Teeth,  disorders  of  the  87,  89* 
Telangiectases  . .  . .  231 

Tenesmus iiSf 

Tenotomy  . .          . .          . .     344 

Terebene     . .          . .          . .     323 

Terson  on  entropion  . .  183 
Therapeutics,  rational  333,  354 
Thermotaxis,  paralysis  of  29 

Thieberge,  G 285 

Thirst          ...       ..          ..        96 

Thompson,  H.        ..          ..      133 

Thomson,  H.  H 72 

Thorax,  deformity  of        .  .      170 

Thorburn,  W 14 

Throat,  disorders  of      201,  203* 
Thrombosis  of  heart         . .      270 
Thymus,  hypertrophy  of    203*, 
209 

Thyreo-globulin  .  .  66,  330 
Thyroid,  deficiency  of  ..  112 

,,  hypertrophy  of       203*, 

207 

„  preparations       . .     330 

,,          pressure  on    203*,  207 


Thyroplasty 

Tic 

Tinea  tarsi 

tonsurans 


•  343 
..  28 
..  181 
253, 338 


,,  versicolor  . .  . .  227 
Tinnitus  158,  163,  213*,  216 
Toe-nail,  ingrowing  . .  230 
Tongue,  retraction  of  . .  287 
,,  swallowing  . .  202 
Tonsils,  enlarged  ..  193,  349 
Tooth-ache  . .  . .  90 

Tourette  on  morphia  . .  280 
Tourniquet,  use  of  . .  338 

Toxaemia  25,  28,  67!',  91,  104, 

n8,    122,    123*,    163,    169, 

201,  203*,  276,  328,  342 
Trachea,  dilatation  of  . .  244 
,,  stenosis  of  203*,  2O7f, 
267*,  272,  343 

Trachoma 172 

Traumatic  neurasthenia  14,  283 
Treatment,  aetiological  . .  302 

,,  injudicious  . .  277f 

Trees,  death  of  . .  . .  263 
Trembling  . .  . .  236 

I  Trendelenburg  on  Vicious 

Circle  . .  . .  93 

Trephining  -  ..  ..  347 
Treves,  F.  . .  . .  31,116 
Trichiasis  . .  . .  174,  183 
Trichloracetic  acid  . .  331 

Trichophytons  . .  226,  338 
Tricuspid  regurgitation  . .  48 
Tropics,  diseases  of  the  63,  in, 
27°.  336 

Trousseau,  A.  . .  . .  292 
Truss,  value  of  . .  . .  334 
Tuberculosis  72,  73*,  74f,  77f, 

121,  204,  232,  242,  296,  308, 

330 

Turgor,  excessive  . .          . .     260 


376 


\Diciou0  Circles  in  Disease 


Turpentine,  exudation  of 

„            use  of  .  . 

Twigs,  death  of     .  .  257*, 

Tympanum,,  catarrh  of     .. 

Tympany,  gastric  .  . 

„           intestinal  .  . 

Typhlitis     ..          ..  .. 

Typhoid  fever        .  .  43, 

Tyrel,  Walter         .  .  .  . 


Page 
256, 
258 
323 
26of 


no 
287 
271 


Udder,  inflammation  of    .  .      252 

Ulcer,  corneal        . .     173*,  i74f 

,,      duodenal     . .          . .    io7f 

„      gastric         . .         97f,  342 

,,      nasal  ..          ..    i95f 

,,      pulmonary  . .      xx. 

,,      septal          ..      191*,  196 

,,      varicose       . .          . .      220 

Unna,  P.  G.     50,  220,  222,  234 

Uraemia      . .  . .  68,  299 

Urbantschitsch  on  deafness    215 

Ureter,  disorders  of  . .    I28f 

,,        diverticulum  of  128,  I3of 

„        kinking  of       123*,    126, 

250 

Urethra,  calculus  of        136,  251 

,,  disorders  of    I35f,   141, 

239*,  288 

,,  stricture  of      123*,   135 

Urethrocele  . .          . .    i35f 

Urethrotomy          . .          . .      344 
Uric  acid,  excess  of  69,  310 

Urinary  disorders       I2if,    123*, 

250f 

Urine,  diminished  excretion 

of         113 

„       retention  of      I3if,   i34f, 
ISO,    239*,    335*.   336,   340 

„       suppression  of        . .        64 


Urticaria     .  .          .  .        223, 

Ustilago      .  .          .  .          .  . 

Uterus,  displacement  of 

M8,  334,  335*.  340, 

„        fibroid  of  .  . 

„         inertia  of       .  .      .  . 

,,         inversion  of          .  . 

„        prolapse  of      139*, 
335*,  340, 

,,         retroversion  of   139 


Page 
229 
261 
nsf, 
34i* 
152 
152 
152 
294, 
34i* 
*,  150 


Vaccine  therapy    . .          . .     330 

Vagina,  irrigations  of       . .      288 

Vaginismus  . .     139*,   I47f 

Valsalvan  inflation  . .      215 

Valve,  rupture  of  cardiac        269 

Varicocele  . .       139*,   143 

Varicose  lymphatics          . .        58 

,,       ulcers      . .          . .      220 

,,       veins,  cf.  Veins 

Vaso-motor  paralysis        26f,  30, 

275 

Vegetable  parasites       210,  226f, 

338 

Vegetarianism       ..  ..      310 

Veins,  congestion  of 

coronary        . .  . .      268 

,,    varicose      37*,  58,  93,  220, 

293*,  294,   335,*  349 

Venesection    75,  279*,  287^  347 

Venosity,  excessive          80,  2O5f 

Venous  stasis         ..          ..      154 

Ventricles,  distension  of 

cerebral  31,  236,   276 

Verminous  bronchitis       . .      244 
Vertigo       ..  16,  218,  287 

Vesical  calculus      131,    133,   343 
Vessels,  ligation  of  . .      349 

Veterinary  diseases  15,  237,  239* 


377 


Page 

Page 

Vicarious  assistance    2,  72,  101, 

IBR 

29lf 

Ward,  G.  R  66 

Vice             .  .             28,   137,   141 

„       H.  M  258 

Vicious  Circles,  aetiology  of         i 

Warfield,  L.  M.      .  .          56,   157 

,,               ,,      and  death, 

Watson-  Williams,  P.        .  .      190 

cf.  Death 

"  Weak-heart"    ..        53,  307* 

„               ,,      chemical    8,  96, 
326 

Weber,  P  294 

,,      classification 

Wecker,  L.             .  .          .  .      176 

of           ..         7 

Weeks,  J.  E  183 

definition  of  xvii. 

Weight  of  body  in  obesity      160, 

162,   1  66 

,,               ,,      in  animals   xix., 

3,  4*,  15,  237*. 

Wells,  H.  G.           .  .          68,   104 

239*,  353 

West,  C  205 

„               „      in  plants  xix.,  5, 

„      S  36,  83,  268 

14,    255,    257*, 

Westcott,  W  266 

353 

"Whites,"  the      ..          ..288 

,,               ,,      mechanical        8 

Wilkinson,  C.         .  .          77,  278 

,,               ,,      organic    .  .         8 

Will  power,  loss  of            13,  282 

„      specific  4,  8,  255, 
264 

Wind-pipe  worm  .  .          .  .     244 

„        Cycle         .  .          .  .       25 

Wind-sucking        .  .         98f,  248 

„         spiral         .  .          .  .        18 

Wool-eating           ..          ..250 

Virgil          280 

Worm  aneurysm  .  .          .  .     241 

Virtuous  Circles       24,    41,    258, 
280,  324,  325 

,,        nodules     .  .          .  .     244 
Worms,  cf.  Parasitic  disorders 

Vis  medicatrix     ..          ..  xviii. 

Visceroptosis        1051,  106,  109, 

3 

126,  334 

Viscosity,  increased            64f,  69 

Yearsley,  P.  M  190 

Vitality,  lowered            172,  187, 

257*,  261 

Z 

Volvulus     344 

Zinc,  sulphate  of  .  .          .  .     327 

Vomiting    ..         89*,  235,  293* 

Zoo-pathology       xix.,    3f,    237f, 

Vulva,  pruritus  of  139*,  146,  332 

239*.  353 

Vulvitis       ..          ..        147.  i65 

Zymotic  disease    .  .          43,  321 

Printed  by 

PETTY  &  SONS,  LTD. 
Reading. 


AA    000376954    4 


